Our findings support the validity of the MFQ ... Requests for reprints to: Dr. Lindsey Kent, Lecturer in Child ... symptoms per se (Kent, Vostanis, & Feehan, 1995).
J. Child Psychol. Psychiat. Vol. 38, No. 5. pp. 565-573, 1997 Cambridge University Press © 1997 Association for Child Psychology and Psychiatry Printed in Great Brilain. All rights reserved 0021-9630/97 $15.00 + 0.00
Detection of Major and Minor Depression in Children and Adolescents: Evaluation of the Mood and Feehngs Questionnaire Lindsey Kent and Panos Vostanis University of Birmingham, U.K.
Catherine Feehan Oaklands Centre, Birmingham, U.K. The detection of major and minor depression in children and adolescents was evaluated in an outpatient sample of 113 children employing the Mood and Feelings Questionnaire (both child and parent versions) and the K-SADS interview. Differences between depressed and nondepressed groups, those with major or minor depression, and depressed children compared with those comorbid for anxiety, were examined. Our findings support the validity of the MFQ as a screening instrument for major and minor depression in a population with a high proportion of depressed cases. High agreement between parent and child ratings was found, with cognitive items being the best predictors of depression. Keywords: Depression, child, adolescent, screening. Abbreviations: AUC: areas under the curve; K-SADS: Schedule for Affective Disorders and Schizophrenia; LR: Likelihood Ratio; MFQ: Mood and Feelings Questionnaire; ROC; Receiver Operating Characteristic.
criteria for major depresssive disorder. Angold (1988a) made distinctions in the use of the term depression for the low end of fluctuating mood, description of unhappiness, symptoms, syndromes, disease and as a cause of handicap. He attributed the inconsistent prevalence rates in the general population to differences in definitions and measures employed by various studies. Cooper and Goodyer (1993), for example, estimated that 20.7% of their sample had experienced depressive symptoms of a lesser severity during the previous year. Monck, Graham, Richman, and Dobbs (1994) estimated that around 20% of adolescent girls in the general population of London had significant mood disturbance. In a review by Angold (1988b), the prevalence rates of major depression in various clinical samples ranged from 0-61 %. In addition, previous studies have shown the rates of comorbidity of depression with anxiety (Kovacs, Gatsonis, Paulauskas, & Richards, 1989) and oppositional/conduct disorder (Angold & Costello, 1993) in this population to be high. Depressive disorder may vary substantially over the course of development, and research to date has largely assumed that diagnostic criteria such as those contained within DSM-III-R (American Psychiatric Association, 1987) and ICD-10 (Worid Health Organisation, 1992), which were originally developed for use in adults, can be applied to children and adolescents. Although children may have unique characteristics in their manifestation of depression, the current approach is to apply the diagnosis when the core criteria have been met. Several instruments, including self-report questionnaires, interviews, and clinical rating scales have been validated for assessment of
Introduction Depression has become widely recognised as a significant psychiatric condition of childhood and adolescence. It is, however, established that there are substantial developmental effects in the expression of affective phenomena, cognitions, and description of depressive symptoms by young people (Harrington, 1994). Depressed children have significant impairment in most psychosocial relationships (Puig-Antich et al, 1985) and show evidence of functional impairment in various cognitive and social domains (Kovacs & Goldston, 1991). Flemming, Offord, and Boyle (1989) estimated, in the Ontario child health study, that major depressive disorder occurred in less than 3 % of school-age children, rising to around 6% in adolescents. Bailly, Beauscart, Collinet, Alexandre, and Parquet (1992) estimated the prevalence of major depression in French high school students, aged 14-23 years, as 4.1 % in males and 4.7 % in females. In a community study by Cooper and Goodyer (1993), employing interview and self-report questionnaires including the Mood and Feelings Questionnaire (MFQ; Costello & Angold, 1988), the prevalence rate for major depressive disorder in British adolescent giris was estimated at 3.6%. However, many more children and adolescents suffer depressive symptoms that do not amount to diagnostic Requests for reprints to: Dr. Lindsey Kent, Lecturer in Child Psychiatry, University of Birmingham, Parkview Clinic, 60, Queensbridge Road, Moseley, Birmingham, B13 8QE, U.K. 565
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depression in children and adolescents (Kazdin, 1990); one such is the Children's Depression Inventory (Kovacs & Beck, 1977), the most widely used measure. The Mood and Feelings Questionnaire (Costello & Angold, 1988) is a well-established, reliable instrument designed to screen for possible depressive symptoms. It was originally constructed to contain items necessary for a DSM-III-R diagnosis of major depression. Wood, Kroll, Moore, and Harrington (1995) examined the psychometric properties of the Mood and Feehngs Questionnaire (MFQ) in 104 adolescent outpatients attending a psychiatric chnic. Their findings support the use of the self-report version of the MFQ as a screening instrument for major depressive disorder. In addition to the literature on child and adolescent depression, we also need to consider methodological issues regarding the detection of child psychiatric disorders. Parent-child agreement on children's symptomatology has often been found to be low (Andrews, Garrison, Kirby, Addy, & McKeon, 1993; Angold, Weissman, et al, 1987; Edelbrock, Costello, Dulcan, Conover, & Kalas, 1986; Phares, Compass, & Howell, 1989). Barrett et al. (1991), in the Newcastle Child Depression Study, found that agreement on the more subjective symptoms was often low. Agreement tends to increase with age of the child (Renouf & Kovacs, 1994) and with more depressive symptoms rather than negative cognitions (Edelbrock et al, 1986; Weismann et al, 1987). In addition, children have been found to report more depressive symptoms about themselves than have their parents (Andrews et al, 1993; Angold, Weissman, et al, 1987; Wood et al, 1995), and features of social maladjustment are often more prominent than depressive symptoms per se (Kent, Vostanis, & Feehan, 1995). Wood et al (1995) examined parent-child agreement employing the MFQ and found a modest correlation (.51) between total child and parent scores. Although the clinical course of depression in children and adolescents is often characterised by short-term remittance (Harrington, 1992), the high rate of suicide (Harrington et al, 1994), recurrence of symptoms (Fleming, Boyle, & Offord, 1993; Lewinsohn, Clarke, Seeley, & Rohde, 1994), and continuation of depressive illness into adult life (Harrington, Fudge, Rutter, Pickles, & Hill, 1990) indicates that satisfactory detection of depressive symptoms within this population is essential. The aim of this paper is first to compare ratings of childhood depression as assessed by children and their parents, using the MFQ in a clinical sample. Second, we aim to examine the MFQ as an instrument for differentiating between children (a) with or without depressive disorders, (b) with or without minor or major depression, and (c) with or without comorbid anxiety or conduct/ oppositional disorders.
Materials and Methods
subsequently excluded due to significant learning disability, leaving a sample of 113 children (56 boys and 57 girls). The primary diagnoses of the sample from the K-SADS interview were minor depression (A'^ = 33), major depression ( J V = 3 2 ) , dysthymia {N = W), anxiety disorder (A^=ll), conduct disorder (TV = 6), oppositional disorder (A'^ = 3), somatoform disorder (A^ = 3), anorexia (A^ = 1), enuresis {N = 3), sleep disorder (A^ = 1), phobic disorder (A'^ = 1), and adjustment reaction (A^ = 1). No psychiatric diagnosis was present in 7 children. Of those suffering from depression or dysthymia, 29 were also comorbid for anxiety, and 11 were comorbid for behavioural problems: 9 for oppositional disorder and 2 for conduct disorder. The mean age of the sample was 12.65 years, with a range of 7 to 17 years.
Methods The Mood and Feelings Questionnaire (Costello & Angold, 1988) is a 33-item rating scale of depressive symptoms for children of 8-18 years of age, based on DSM-III-R criteria (Harrington & Shariff, 1992). Both a child ( ; M F Q - C ) and parental (MFQ-P) version with corresponding items are completed. Data have been presented on its test-retest reliability and validity (Angold, 1989). A subscale referred to as the NET-MFQ consists of 11 items of the MFQ, and has been demonstrated by Costello and Angold (1988) to have the best discriminatory power for quick identification of children at risk of depression. A NET score was generated for both the MFQ-C and MFQ-P for each child. In addition, a CORE group of items exists from the MFQ that refers to affective and cognitive aspects of depression. Scores were also calculated for these scales. Two of the most recent papers employing the use of the MFQ as a screening instrument have proposed the use of cut-off scores to distinguish between diagnostic groups. Cooper and Goodyer (1993) divided their sample into low (MFQ < 20), medium (MFQ 20-34), and high (MFQ < 34) scorers on the MFQ. Wood et al. (1995) found that a cut-off score of 27 on the MFQ-C, and 21 on the MFQ-P, gave the best diagnostic confidence for major depression. Children were therefore allocated to different groups according to these cut-off scores and these measures were also employed in this study. Each child and parent was interviewed using the child version of the Schedule for Affective Disorders and Schizophrenia: K-SADS (Puig Antich & Chambers, 1978), to estabhsh the diagnosis during the current episode (previous 2 weeks). This is a widely used semi-structured interview with children aged 6-17 and their parent(s) or main carer. It covers a broad range of childhood psychiatric diagnoses but its content is heavily weighted in favour of depression.The K-SADS version used in this study gives DSM-III-R diagnoses (American Psychiatric Association, 1987). Acceptable inter-rater reliability and shortterm test-retest reliability of the K-SADS have been demonstrated (Chambers et a l , 1985). Validation of the K-SADS is limited primarily to the area of depressive disorders (Edelbrock & Costello, 1988). Depressive disorders and conduct disorders can be assessed reliably without limiting the validity of these diagnoses, but the reliability of the K-SADS has been reported to be lower with anxiety disorders (Chambers et al., 1985). Interviewers (PV and CF) were blind to the child's MFQ scores. Fifteen interviews were rated independently by the two assessing clinicians. Their agreement on presence/absence and type of psychiatric diagnosis was 100%.
Sample The sample consisted of 114 consecutive attenders at 4 Child and Adolescent Units over a 2-year period. All children were administered the MFQ (Costello & Angold, 1988) and interviewed according to standardised assessment schedules (KSADS: Puig-Antich & Chambers, 1978). One child was
Statistical Analyses The Chi-squared likelihood ratio was calculated for comparison of categorical variables and the Mann-Whitney U test was employed for comparison of continuous variables. Spearman's correlation coefficients were employed and the
EVALUATION OF THE MOOD AND FEELINGS QUESTIONNAIRE Wilcoxon signed ranks test was used for matched-paired data. Forced entry logistic regression determined which independent variables best predicted various dependent variables. Receiver Operating Characteristic (ROC) curve analysis was performed to provide information regarding sensitivity, specificity, and predictive values of the MFQ. Essentially this involves plotting the true positive rate (sensitivity) against the false positive rate (1-specificity). The area under the curve obtained ranges from .5 to 1.0 and provides an indication of the diagnostic accuracy of the test, the highest accuracy being equivalent to 1.0.
Parent-Child
Results Agreement
Overall, the mean MFQ-C score (27.05, SD = 13.73) and MFQ-P score (27.63, SD = 14.99) did not differ significantly {Z - —0.24, n.s.). The correlation coefficient for parent and child total MFQ scores was .65 {p < .001), for NET MFQ scores was .51 {p < .001), and for CORE MFQ scores was .55 {p < .001). All matching items of the MFQ-C and MFQ-P correlated significantly with each other, with correlations ranging from .3-.6 and p values all < .003. For the depressed and dysthymic children {N = 76), the mean MFQ-C score was 31.43 {SD = 12.72) and the mean MFQ-P score was 32.38 {SD = 13.77). Again these means did not differ significantly (Mann-Whitney test; Z = —0.37, n.s.). There was a trend for more of the depressed adolescents to be girls (/"^ Likelihood Ratio [L.R.] = 2.76, n.s.). Spearman's correlation coefficient for the parent and child total scores was .51 {p < .001), for NET scores was .34 {p < .005), and for CORE scores was .36 {p < .005). All but two matching MFQ-C and MFQ-P items correlated significantly in the depressed only children. These were "I was very restless" {r = .008, n.s.) and " I felt miserable or unhappy" (r = .2, n.s.).
Depressed vs. Nondepressed Psychiatric Group The analysis involved 106 children, as 7 children did not receive a diagnosis. The depressed group consisted of those suffering from major and minor depression, and dysthymia. Girls were more likely to be depressed than boys {f L.R. = 8.66, p < .005) and children and adolescents were equally distributed between the depressed and nondepressed groups. Total MFQ-C and MFQ-P scores in the depressed group were significantly higher than in the nondepressed group and all the MFQ subscales scored significantly higher in the depressed group (Table 1). Each individual item scored by parents was significantly higher in the depressed group. All except four
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items; "I thought bad things would happen to me" , " I feh so tired I sat around and did nothing", "I was a bad person ", and " sometimes I blamed myself for things that weren't my fault" were scored significantly higher by depressed children. Cut-off scores previously employed by Wood et a l (1995) significantly differentiated the two groups into depressed and not depressed; MFQ-C cut-off (/^ L. R. = 13.24, p < .0005) and MFQ-P cut-off (/'^ L.R. = 14.64, p < .0005). Cooper and Goodyer's three-group classification (1993) again significantly separated the children, with the depressed children falling into the medium and high scoring groups (/'' L. R. = 19.87,;? < .0001), and the nondepressed children into the low scoring group. Forced entry logistic regression, with sex as a covariate, was employed to determine which independent variables best predicted whether children suffered from depression or not. The MFQ-P total scores alone (102 cases), when entered with the MFQ-C total scores, best predicted whether the children were depressed or not (B = — 0.68,r'^ = .78,;? < .01). Examining the MFQ-C items (95 cases), the best predictors of whether children were depressed or not were the items; " I did everything wrong ", " I thought I looked ugly", " I thought nobody really loved me" (r'^ = . 9 2 a n d B = -5.26,p < .0\;B = -3.92,/? < .01; B = — 4.02,/? < .05respectively for each item), with depressed children scoring higher on these items. Of the MFQ-P items "He/she found it hard to think properly or concentrate", " He/she thought they were a bad person", "He/she felt lonely " and " He/she felt they were no good anymore" were the best predictors of whether children were diagnosed as depressed or not (r^ = .86 and B = -4.67,p < .005; B = 8.16,/? < .005; B = -3.14,/? < .05 and B = —4.23,/? < .05 for each item respectively). None of Costello and Angold's NET and CORE subscales, were of higher predictive value than any other. ROC curve analysis was performed to study the power of the MFQ to discriminate between depressed and nondepressed subjects. Table 2 indicates the cut-off values for the MFQ that correspond to the highest accuracy of the instrument with the corresponding sensitivities, specificities, and areas under the curve (AUC). Predictive values are also given for a base rate of depression of 50 % in our population. The difference between the MFQ-C and MFQ-P AUC was not significant (difference between curves = .03, n.s.).
Major vs. Minor Depression Of the whole sample of 113 children, 65 received a diagnosis of major (A'^ = 32) or minor (A^ = 33)
Table 1 Mean MFQ~C and MFQ-P Scores for Depressed vs. Nondepressed Psychiatric Group MFQ Total MFQ-P Total MFQ-C NET MFQ-P NET MFQ-C CORE MFQ-P CORE MFQ-C
Depressed mean score
Nondepressed mean score
Z score
P
32.38 31.43 11.88 11.95 14.72 14.47
16.70 17.86 6.13 6.28 7.03 7.07
-4.81 -4.62 -4.63 -471 -452 -4.54
be an indication of the ability of the
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instrument to isolate depression from comorbid conditions or a samphng or diagnostic phemomenon. In summary, our study supports the validity of the Mood and Feelings Questionnaire as a useful screening instrument for minor and major depression in populations with a high proportion of depressed cases. The categories of low, medium, and severe scores on the MFQ, as used by Cooper and Goodyer (1993), can usefully be employed to assess both the presence and the severity of depression. In addition, certain items of the MFQ, particularly the more cognitive depressive items, appear to be useful in assessing severity. Clinicians are often reluctant to question parents regarding their child's depressive thoughts, particularly suicidal thoughts. This appears to be partly for fear of upsetting parents, but also because it is felt that parents do not know what their children are feeling or thinking. Our findings suggest that parents are more aware of their childrens' depressive cognitions than previously thought, and indeed, that they detect these cognitious more so than depressive symptoms in major depression. They also indicate the usefulness of cognitive-behavioural therapies designed to address depressive cognitions (Fine, Forth, Gilbert, & Haley, 1991; Reynolds & Coates, 1986; Stark, Reynolds, & Kaslow, 1987) and therapies developed for use in clinical cases (Vostanis, Feehan, Gratton, & Brickerton, 1996; Vostanis & Harrington, 1994). Future research needs to establish the vahdity of the MFQ as a screening measure in children with dysthymic disorder, as children with dysthymia have been found to be m.ore impaired than children with major depression in social functioning and other characteristics (Ferro, Carlson, Grayson, & Klein, 1994). Finally, the validity of DSM diagnostic criteria in childhood depression requires further investigation. Acknowledgements—The authors wish to thank the children and parents for their participation and the Consultant Child and Adolescent Psychiatrists whose patients were involved in the study.
References Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987). Child/Adolescent behavioural and emotional problems: Implications of cross-informant correlations for situational speeificity. Psychological Bulletin. 101. 213-232. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental health disorders-DSM-IH-R (3rd edn., revised), Washington, DC: American Psychiatric Association. Andrews, V. C , Garrison, C. Z., Kirby, L. J., Addy, C. L., & McKeon, R. E. (1993). Mother-adolescent agreement on the symptoms and diagnosis of adolescent depression and conduct disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 731-737. Angold, A. (1988a). Childhood and adolescent depression I. Epidemiological and aetiological aspects. British Journal of Psychiatry, 152, 601-617. Angold, A. (1988b). Childhood and adolescent depression IL Research in clinical populations. British Journal of Psychiatry, 153, 476-492. Angold, A. (1989). Structured assessments of psychopathology in children and adolescents. In C. Thompson (Ed.), The instruments ofpsychiatric research (pp. 271-304). New York: Wiley.
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Angold, A., & Costello, E. J. (1993). Depressive co-morbidity in children and adolescents. Empirical, theoretical and methodological issues. The American Journal of Psychiatry, 150, 1779-1791. Angold, A., Costello, E., Pickles, A., Winder, F., & Silver, D. (1987). The development of a questionnaire for use in epidemiological studies of depression in children and adolescents. Unpublished manuscript. Angold, A., Weissman, M. M., John, K., Merikangas, K. R., Prusoff, B. A., Wickramaratne, P., Gammon, G. D., & Warner, V. (1987). Parent and child reports of depressive symptoms in children at low and high risk of depression. Journal of Child Psychology and Psychiatry, 28, 901-915. Bailly, D., Beuscart, R., Collinet, C , Alexandre, J. Y., & Parquet, Ph.J. (1992). Sex differences in the manifestations of depression in young people. A study of French high school students. Part I: Prevalence and clinical data. European Child and Adolescent Psychiatry, 1, 135-145. Barrett, M. L., Berney, T. P., Bhate, S., Famuyiwa, O. O., Fundudis, T., Kolvin, I., & Tyrer, S. (1991). Diagnosising childhood depression. Who should be interviewed-Parent or child? The Newcastle child depression project. British Journal of Psychiatry, 159, (suppl. 11), 22-27. Chambers, W. J., Puig-Antich, J., Hirsch, M., Paez, P., Ambrosini, P. J., Tabrizi, M. A., & Davies, M. (1985). The assessment of affective disorders in children and adolescents by semi-structured interview. Archives of General Psychiatry, ^2,696-702. Cooper, P. J., & Goodyer, I. (1993). A community study of adolescent girls: Estimates of symptoms and syndrome prevalence. British Journal of Psychiatry, 163, 369-374. Costello, E., & Angold, A. (1988). Scales to assess child and adolescent depression. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 726-737. Edelbrock, C , & Costello, A. (1988). Structured psychiatric interviews for children. In M.Rutter, H. Tuma, & 1. Lann (Eds.), Assessment and diagnosis in child psychopathology (pp. 87-112). London: Fulton. Edelbrock, C , Costello, A. J., Dulcan, M. K., Conover, N. C , & Kalas, R. (1986). Parent-child agreement on child psychiatric symptoms assessed via structured interview. Journal of Child Psychology and Psychiatry, 27. 181-190. Ferro, T., Carlson, G. A., Grayson, P., & Klein, D. N. (1994). Depressive disorders: Distinctions in children. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 664^670. Fielstein, E., Klein, M. S., Fischer, M., Hanan, C , Koburger, P., Schneider, M. J., & Leitenberg, H. (1985). Self-esteem and causal attributions for success and failure in children. Cognitive Therapy and Research, 9, 381-398. Fine, S., Forth, A., Gilbert, M., & Haley, G. (1991). Group therapy for adolescent depressive disorder: A comparison of social skills and therapeutic support. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 79-85. Fine, S., Haley, G., Gilbert, M., & Forth, A. (1993). Self-image as a predictor of outcome in adolescent major depressive disorder. Journal of Child Psychology and Psychiatry, 34, 1399-1407. Fleming, J., BoyJe, M., & Offord, D. (1993). The outcome of adolescent depression in the Ontario Health follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 28-33. Fleming, J. E., Offord, D. R., & Boyle, M. H. (1989). Prevalence of childhood and adolescent depression in the community: Ontario child health study. British Journal of Psychiatry, 155, 647-654. Garber, J., Weiss, B., & Shanley, N. (1993). Cognitions, depressive synptoms, and development in adolescents. Journal of Abnormal Psychology, 102, 47-57.
Harrington, R. (1992). The natural history and treatment of child and adolescent affective disorders. Journal of Child Psychology and Psychiatry, 33, 1287-1302. Harrington, R. (1994). Affective disorders. In M. Rutter, L. Hersov, & E. Taylor (Eds.), Child and adolescent psychiatry: Modern approaches, 3rd edn. (pp. 330-350). Oxford: Blackwell. Harrington, R., Bredenkamp, D., Groothues, C , Rutter, M., Fudge, H., & Pickles, A. (1994). Adult outcomes of childhood and adolescent depression. III. Links with suicidal behaviours. Journal of Child Psychology and Psychiatry, 35, 1309-1319. Harrington, R., Fudge, H., Rutter, M., Pickles, A., & Hill, J. (1990). Adult outcomes of childhood and adolescent depression: Psychiatric status. Archives of General Psychiatry, 47, 465-473. Harrington, R., & Shariff, A. (1992). Choosing an instrument to assess depression in young people. Association of Child Psychologists and Psychiatrists Newsletter, 14, 279-282. Kazdin, A. (1990). Childhood depression. Journal of Child Psychology and Psychiatry, 31, 121-160. Kent, L., Vostanis, P., & Feehan, C. (1995). Teacher reported characteristics of children with depression. Educational and Child Psychology, 12, 62-1Q. King, C. A., Naylor, M. W., Segal, H. G., Evans, T., & Shain, B. N. (1993). Global self-worth, specific self-perceptions of competence, and depression in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 745-751. Kovacs, M., & Beck, A. T. (1977). An empirical-clinical approach towards a definition of childhood depression. In J. G. Schulterbrandt & A. Raskin (Eds.), Childhood depression (pp. 1-25). New York: Raven Press. Kovacs, M., Gatsoni, C. Paulauskas, S., & Richards, C. (1989). Depressive disorders in childhood: IV. A longitudinal study of co-morbidity with and risk for anxiety disorders. Archives of General Psychiatry. 46, 116-1%2. Kovacs, M., & Goldston, D. (1991). Cognitive and social cognitive development of depressed children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 388-392. Lewinsohn, P., Clarke, G., Seeley, J., & Rohde, P. (1994). Major depression in community adolescents: Age at onset, episode duration and time to recurrence. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 809-818. Marton, P., Connolly, J., Kutcher, S., & Korenblaum, M. (1993). Cognitive social skills and social self-appraisal in depressed adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 739-744. McCauley, E., Mitchell, J., Burke, P., & Moss, S. (1988). Cognitive attributes of depression in children and adolescents. Journal of Consulting and Clinical Psychology, 56, 903-908. Monck, E., Graham, P., Richman, N., & Dobbs, R. (1994). Adolescent girls 1. Self-reported mood disturbance in a community population. British Journal of Psychiatry, 165, 160-169. Phares, V., Compass, B. E., & Howell, D. C. (1989). Perspectives on child behaviour problems: Comparisons of children's self reports with parent and teacher reports. A Journal of Consulting and Clinical Psychology, 1, 68-71. Puig-Antich, J., & Chambers, W. (1978). The schedule for affective disorders and schizophrenia for school aged children. Unpublished interview schedule. New York State Psychiatric Institute. Puig-Antich, J., Lukens, E., Davies, M., Goetz, D., BrennanQuattrock, J., & Todak, G. (1985). Psychosocial functioning
EVALUATION OF THE MOOD AND FEELINGS QUESTIONNAIRE in prepubertal major depressive disorders: I. Interpersonal relationships during the depressive episode. Archives of General Psychiatry, 42, 500-507. Renouf, A. G., & Kovacs, M. (1994). Concordance between mothers' reports and children's self reports of depressive symptoms: A longitudinal study. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 208-216. Reynolds, W. M., & Coats, K. 1. (1986). A comparison of cognitive-behavioural therapy and relaxation training for the treatment of depression in adolescents. Journal of Clinical and Consulting Psychology, 54, 653-660. Stark, K. D., Humphrey, L. L., Laurent, J., Livingstone, R., & Christoper, J. (1993). Cognitive, behavioural, and family factors in the differentiation of depressive and anxiety disorders during childhood. Journal of Consulting and Clinical Psychology, 61, 878-886. Stark, K., Reynolds, W., & Kaslow, N. (1987). A comparison of the relative efficacy of self-control therapy and a behavioural problem-solving therapy for depression in children. Journal of Abnormal Psychology, 15, 91-113. Vostanis, P., Feehan, C , Gratton, E., & Bickerton, W. L.
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(1996). Treatment for children and adolescents with depression: Lessons from a controlled trial. Clinical Child Psychology and Psychiatry, 1, 199-212. Vostanis, P., & Harrington, R. (1994). Cognitive-behavioural treatment of depressive disorder in child psychiatric patients: rationale and description of a treatment package. European Child and Adolescent Psychiatry, 3, 111-123. Weissman, M., Wickramaratne, P., Warner, V., John, K., Prusoff, B., Merikangas, K., & Gammon, D. (1987). Assessing psychiatric disorders in children—discrepancies between mothers' and children's reports. Archives of General Psychiatry, 44, 747-753. Wood, A., Kroll, L., Moore, A., & Harrington, R. (1995). Properties of the mood and feelings questionnaire in adolescent psychiatric outpatients: A research note. Journal of Child Psychology and Psychiatry, 36, 327-334. World Health Organisation. (1992). The ICD-10 classification of mental and behavioural disorders. Geneva: World Health Organisation. Accepted manuscript received 9 September 1996
