The Children’s Depression Inventory (CDI)

as measure of depression in Swedish

adolescents. A normative study
TORD IVARSSON, PER SVALANDER, OEYSTEIN LITLERE

Ivarsson T, Svalander P, Litlere O. The Children’s Depression Inventory (CDI) as measure of

depression in Swedish adolescents. A normative study. Nord J Psychiatry 2006;60:220
226.
Oslo. ISSN 0803-9488.

Self-rating scales are an economical and practical aid in the diagnostic work-up. However,
normative data from the general population are needed to interpret scores. Four hundred and
five adolescents selected to be fairly representative of the general population (both ethnical
Swedes and born abroad) filled in a questionnaire containing the Children’s Depression
Inventory (CDI), the Multidimensional Anxiety Scale for Children (MASC) and background
data (including socio-economic status (SES). The CDI was reliable in terms of internal
consistency (0.86) with a mean inter-item correlation of 0.18 and item-total score correlations
ranging from 0.26 to 0.57. The CDI sub-scales (Negative Mood, Ineffectiveness, Anhedonia and
Negative Self-esteem had good internal consistency values slightly above 0.60, except for sub-
scale Interpersonal Problems with poor internal consistency (0.36). The 90th and 95th
percentiles respectively were defined by scores 15 and 18 and above for boys and by scores 20
and 23 and above for girls. Common correlates of high scores were female gender, broken family
but not SES, nor ethnicity. Also, some estimates of the convergent validity of the CDI were
found in a Pearson correlation of 0.40 with the MASC total score and in the capacity of the CDI
(predictive validity); OR /1.1 in predicting suicidal ideation. The CDI has some, but as of yet
not sufficient indications of being a valid and reliable measure of depression in adolescence and
scores can be used to indicate, though not prove the absence or presence of, depression.
’ CDI, Children’s Depression Inventory, Depression, Normative data.
Tord Ivarsson, Department of Child and Adolescent Psychiatry, Göteborg University,
Kungsgatan 12, SE-411 19 Göteborg, Sweden, E-mail: tord.ivarsson@vgregion.se; Accepted
28 September 2005.

epressive symptoms are among the most common
D self-reported psychiatric health complaints in ado-
lescents both in Sweden (1
5) and in other countries (6

10); see Birmaher et al. (11) for a review. Different
methodologies such as clinical interviews, structured
interviews and self-rating scales have been developed
for assessing depressive symptoms. Reviews by Costello
& Angold (12) and Hodges (13) have discussed the pros
and cons of these measures [see also Rutter (14) and
Costello (15) for a discussion and Shedler (16) for a
critique].
The Children’s Depression Inventory (CDI) is a self-
rating scale developed specifically for young people
modelled after the adult scale, the Beck Depression
Inventory (BDI; 17, 18). As in the BDI, the cognitive
symptoms of depression are a dominant feature of the
scale. The CDI combines aspects of the clinical/catego-
rical approach and of dimensional measurement. The
clinical/categorical approach is evidenced in that it
covers most of the symptoms of major and minor
depression according to the DSM IV (19). The dimen-
sional nature can be seen in that the items are scored
quantitatively (0
2) and that the scores are combined to
sub-scales and to a total score.
Previous international studies have shown the CDI to
be a reliable measure with high internal consistency with
Cronbach alphas ranging from 0.71 to 0.89. The CDI
sub-scales have also shown good to fair internal
consistency [e.g. (18): Negative Mood 0.62; Interperso-
nal Problems 0.59; Ineffectiveness 0.63; Anhedonia 0.66
and Negative Self-esteem 0.68]. The test
retest reliabil-
ity has ranged from correlations of 0.38 to 0.87
depending upon the time interval (from 1 week to 1
year; 20) and whether the subjects studied have been
clinical (21, 22) or non-clinical (20).

# 2006 Taylor & Francis DOI: 10.1080/08039480600636395


The validity of the CDI has been assessed in many
studies. Kovacs herself failed to show the CDI having
criterion validity in a comparison of clinical cases with
depressive disorders and a non-clinical comparison
group (18), as did Saylor et al. (22), while others have
found good criterion validity (23, 24). However, Carey et
al. (23) found that the CDI could not differentiate
between different clinical groups. One aspect of validity,
the so-called convergent validity, is the tendency for a
scale, e.g. the CDI, to co-variate with well-established
measures of the same construct or with phenomena (e.g.
anxiety) that are well known to co-exist with depression.
The convergent validity of the CDI has been documen-
ted in many studies (18). The convergent validity of the
CDI relative to another well-known measure of depres-
sion, the Center for Epidemiological Studies Depression
Scale (CES-D), was moderate (25). Furthermore, Ollen-
dick & Yule (26) noted a moderately strong correlation
in children between the CDI and the Revised Children’s
Manifest Anxiety Scale (RCMAS). Normative data and
reliability data for children 8
13 years of age were
produced by Larsson & Melin (2), as is now the case for
adolescents.
Aims
We aimed to study the CDI measure in adolescents from
the general population in order to obtain normative data
including scores associated with higher percentiles that
might be of use to interpret CDI scores in clinical
situations. A secondary aim was to study the internal
consistency and the convergent validity of the CDI.
Methods
Subjects
The study group consists of 405 adolescents (192 boys
and 210 girls
missing data as to gender: three indivi-
duals). The adolescents were from four different schools,
selected so that the adolescents should be reasonably
representative of Swedish adolescents. Both inner city,
suburban and rural areas were tapped. Two hundred and
eighty-three pupils attended junior high school (130 boys
and 153 girls), whereas another 119 attended senior high
school (general society oriented programme: 31 boys and
49 girls; hotel and restaurant programme: seven boys
Table 1. Socio-economical status versus ethnicity.
Hollingshead 9-factor Socio-economic index
All Swedish
Low ( B/3)
Medium (3
7)
Highest ( /7)
Total
NORD J PSYCHIATRY ×VOL 60×NO 3×2006
CDI SWEDISH NORMATIVE DATA
and eight girls; technical programme: 24 boys and no
girls). The gender differences across programmes were
statistically significant (x2(4, n /402) /29.24, P B/
0.0001). Because of practical limitations, we could not
sample all senior high school programmes but tried to
make it representative of both theoretically and practi-
cally inclined programmes.
The adolescents’ age ranged from 13 to 16 with about
20
25% in each age group. Thirteen adolescents did not
produce a CDI that could be scored and 15 did not
produce a MASC. Also, three persons did not state their
gender and 10 did not state their family background,
although all but one individual gave their parents’
ethnical roots. Another 15 individuals volunteered no
information about their parents’ work. Furthermore,
four adolescents gave no information about illness/
handicaps and 10 no information about contacts with
the health system. Most individuals failed one scale;
only eight individuals missed out on two or more of the
scales or on data mentioned above.
The socio-economic status (SES) of the adolescents
was assessed through the Hollingshead (27) socio-
economic index estimated from the parents’ occupation
giving a score ranging from 1 to 9, taking into
consideration the educational demands and the status
within society of each occupation. The mean index was
4.7 (standard deviation, s /1.9) for the entire group. As
can be seen from Table 1 (where SES is categorized as
low, medium and high), there was a significant relation-
ship between the ethnical origin and SES in that
adolescents of Swedish origin were more likely to belong
to the medium (3
7) to high (]/7) levels of SES while
adolescent of non-Swedish or mixed descent were more
likely to belong to the medium to low (B/3) levels. The
difference was statistically significant (x2(df /4) /32.35,
P B/0.0001). There were no differences in regard to SES
across gender, nor in regard to living with both
biological parents or not.
A majority (69.4%) of the adolescents lived with their
parents, the largest minority lived with their mothers
(14.7%), almost one in 10 (10.9%) alternated between
their mother and father, a few (2.8%) lived with their
fathers and finally a few (2.2%) lived in other arrange-
ments.
Ethnicity
Swedish/migrant All migrant Total
21 19 7 47
182 32 32 246
54 3 6 63
257 54 45 356
221
T IVARSSON ET AL.
Procedure
Two last-year psychology students (second and third
author) visited the school, informed teachers and pupils
and distributed the questionnaires and supervised the
adolescents when filling in the questionnaire. We tried to
reduce attrition by giving a second chance for pupils who
were not in school on the day of the study. Thus, six
adolescents were ‘‘saved’’ to the study. The questionnaire
was filled anonymously, and each questionnaire was
given a special code number. The questionnaire con-
sisted of two parts: part one concerning personal and
socio-economic information and part two contained the
Children’s Depression Inventory (17). In the same study,
normative data for the Mendelson et al. (28) Body-
Esteem Scale for Adolescents and Adults (BESAA) and
the Multidimensional Anxiety Scale for Children
(MASC; 29) were also gathered and will be published
separately.
Measures
Children’s Depression Inventory
The CDI (17) is a self-rating scale modelled on the BDI
(30) and adapted to young people 7
17 years of age. The
depressive symptoms assessed includes cognitive, affec-
tive, somatic and behavioural aspects and the 27 items
are scored from 0 to 2, where 0 means the symptom is
not present, 1 the symptom is present and mild, and 2
the symptom is present and marked. The CDI takes
about 10
20 min to fill in. The CDI contains five sub-
scales: Negative Mood, Interpersonal Problems, Ineffec-
tiveness, Anhedonia and Negative Self-esteem. The CDI
was translated to the Swedish language in accordance
with an agreement between Dr Kovacs and Dr Larsson
by a bilingual translator. The translation was then
checked by two experienced clinicians independently
and compared with the original and disagreements were
resolved by conference (31; personal communication).
No back-translation was done as the author did not
demand this.
MASC
In this study, the convergent validity of the CDI was
assessed through its correlation with the MASC total
scores. The rational being that anxiety, through many
studies, has been shown to be associated with depression
(26, 32
36). The MASC was developed by March et al.
(29, 37) for use with anxious children and adolescents. It
is a 39-item self-rating scale. Reliability and validity data
from an American sample has been published (29, 37).
Swedish norms will presently be published from the
current sample. The Swedish MASC is used in the study
by permission from Dr March. The MASC items are
scored by the respondent on a scale ranging from 0 to 3,
where 0 signifies that the symptom never applies; 1 that
222
the symptom applies rarely; 2 that the symptom applies
sometimes; and 3 that the symptom applies often.
Statistical analysis
We used chi-square tests for categorical data. Contin-
uous data were studied using t -tests and ANOVA
analyses. A Bonferroni correction for multiple compar-
isons of means was used, leading to only P -values less
than 0.005 being considered statistically significant.
Logistic regression analyses were used to determine
which items best predicted suicidal adolescents.
Results
Reliability analysis
The overall internal consistency (Cronbach alpha) of the
CDI was 0.86. The inter-item correlations ranged from
/0.04 to 0.47 with a mean correlation of 0.18 and the
item-total scale correlations ranged from 0.26 (Item 12:
Likes to be with people) to 0.57 (Item 3: Doing right/
wrong). Most CDI sub-scales showed likewise reason-
able internal consistency: Negative Mood had a full sub-
scale alpha of 0.63 and item-total correlations ranging
from 0.31 (Item 1: Feeling sad) to 0.47 (Item 11: Things
bother me); Ineffectiveness had a full sub-scale alpha of
0.63 and item-total correlations ranging from 0.33 (Item
24: Be as good as others) to 0.47 (Item 23: Quality of
schoolwork); Anhedonia had a full sub-scale alpha of
0.62 and item-total correlations ranging from 0.16 (Item
19: Worries about aches and pains) to 0.45 (Item 20:
Feeling alone) and finally Negative Self-esteem that had
a full sub-scale alpha of 0.62 and item-total correlations
ranging from 0.29 (Item 9: Suicidality) to 0.54 (Item 7:
Self-hate). However, the internal consistency of Inter-
personal Problems was low with a full sub-scale alpha of
0.36 and item-total correlations ranging from 0.16 (Item
26: Obedience) to 0.26 (Item 27: Getting along with
people).
Descriptive data
There were quite large gender differences with regard to
the CDI total scores and to some of the sub-scales (Table
2), especially with regard to the mood and the negative
self-esteem sub-scales. No gender differences were seen
on the sub-scales for Interpersonal Problems and
Anhedonia.
Forty-six adolescents (female/male /34/12, P /0.002,
Fisher’s exact test) had scores at or above the 90th
percentile (scores of 17 and above) and out of those, 19
youngsters (female/male /14/5, P /0.049, Fisher’s exact
test) scored at or above the 95th percentile (scores of 21
and above). Scores defining the percentiles for the CDI
total score and sub-scales for the two genders can be
found in Table 2.
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 CDI SWEDISH NORMATIVE DATA

Table 2. Descriptive data for the CDI and its sub-scales.

P, gender Score for 90th Score for 95th

Measure Gender n Mean s t (df)/x difference percentile percentile

CDI Negative Mood Boys 184 1.8 1.58 t (374.7)/6.15 0.0001 4.0 5.0
Girls 206 2.9 2.12 5.0 7.0
CDI Interpersonal Problems Boys 185 .60 .94 t (389)/0.85 n.s. 2.0 2.0
Girls 206 .68 .93 2.0 3.0
CDI Ineffectiveness Boys 185 1.5 1.34 t (389)/2.59 0.010 3.0 4.0
Girls 206 1.9 1.69 4.0 5.0
CDI Anhedonia Boys 185 2.6 2.25 t (389)/1.38 n.s. 5.5 7.0
Girls 206 2.9 2.36 6.0 8.0
CDI Negative Self-esteem Boys 185 1.1 1.20 t (376.3)/4.37 0.0001 3.0 3.75
Girls 207 1.7 1.63 4.0 5.0
CDI Total Score Boys 184 7.5 5.27 t (377.6)/4.19 0.0001 14.5 17.75
Girls 206 10.1 6.98 19.3 23.0

Gender differences where equal variances could not be assumed can be seen where df values are below 385. Scores for 90th and 95th percentiles of
CDI and sub-scales are included.
s, standard deviation.

Convergent and predictive validity, common
correlates
We studied the convergent validity of the CDI total
scores and sub-scales in respect to the correlation with
the MASC: Total scores (Pearson r /0.40, P B/0.001);
Negative Mood (r/0.45, P B/0.001); Anhedonia (r/
0.35, P B/0.001); Negative Self-esteem (r/0.34, P B/
0.001); Ineffectiveness (r /0.22, P B/0.001) and Inter-
personal Problems (r /0.02, n.s.).
One CDI item taps suicidal ideation (SI). The total
score of the other CDI items ability to predict SI was
tested in a backward elimination logistic regression
analysis. Some factors shown above or below, or in
previous research to be correlates of depression such as
gender, SES, family intactness, ethnical origin and
overall anxiety score on the MASC, were included in
the analysis. Four factors were retained (classifying 81%
of the adolescents correctly): CDI total score, gender
(girls were more likely to have SI), ethnical origin
(adolescents born abroad were less likely to have SI)
and MASC total scores (weak predictor; Table 3).
Re-analysing, using the CDI sub-scales as predictors,
we found only Negative Mood to be retained as a
predictor and non-Swedish ethnical origin as a protec-
tive factor (81.1% adolescents were classified correctly).
Regarding socio-economic factors, there were also
some differences in respect to mean CDI scores for
adolescents who came from broken homes (n /117) as
compared to those from intact families (n/263) on the
CDI (mean /10.59/7.6 and mean /8.19/5.6 respec-
tively, t(381) /3.54, P /0.0001). However, the SES of
the family was weakly negatively correlated with the CDI
(Pearson r/ /0.046, n.s.). Adolescents with at least one
parent born in Sweden (n/332) tended to differ from
adolescents with both parents born abroad (n /63) on
some of the CDI sub-scales [e.g. Negative Mood

Table 3. Prediction of suicidal ideation using backward elimination logistic regression analysis for (1) CDI total score and (2) for
CDI sub-scales.

95% confidence interval for odds ratio

B SE P OR Lower Upper

(1) The predictors could classify 81% of the adolescents correctly. The model was
significant x2 (df/4)/84.1, P B/0.0001
CDI Total Score .16 0.03 0.0001 1.1 1.1 1.2
Gender .6 0.3 0.06 1.8 0.97 3.4
Ethnical origin /1.0 0.5 0.04 0.36 0.13 0.96
MASC Total Score .02 0.01 0.09 1.0 0.99 1.04
Constant /3.55 0.86 0.0001 0.03
(2) The predictors could classify 81.1% of the adolescents correctly. The model was
significant x2(df/2)/68.9, P B/0.0001
CDI Negative Mood .56 0.08 0.0001 1.75 1.5 2.0
Ethnical origin /1.4 0.47 0.004 0.25 0.1 0.64
Constant /1.27 0.54 0.018 0.28

NORD J PSYCHIATRY ×VOL 60×NO 3×2006 223

T IVARSSON ET AL.

(mean /2.89/2.1 and mean /2.39/1.9 respectively,
t(390) /1.97, P /0.05) and the Negative Self-esteem
sub-scale (mean /1.19/1.4 and mean /1.59/1.5 respec-
tively, t(392) /1.99, P /0.047)] but not on the CDI total
score.
Age trends in depression scores
There was a trend for CDI scores to increase year by
year (by 0.9 points per year) in adolescence. As can be
seen from Fig. 1, the current study is well in consonance
with the age trends in childhood as shown by Larsson &
Melin (2), whose figures are depicted in Fig. 1.
Discussion
Overall, the study indicated that the CDI shows some
indicators of reliability and convergent validity and
consequently could be cautiously used with adolescents
as a measure of depressive symptoms although not as a
criterion of a depressive disorder.
The internal consistency reliability coefficients for the
total CDI (0.86) were adequate and well in accordance
with previously published studies (2, 18, 20, 22, 38).
However, it was a weakness of the current study that the
test
retest reliability was not included. Our reliability
data indicated that the CDI sub-scale Interpersonal
Problems is not internally consistent.
The validity of the CDI was studied in two ways. First,
the CDI and the MASC total score were moderately
correlated, thus indicating some convergent validity for
the CDI total score as well as for the CDI sub-scales
Negative Mood, Anhedonia and Negative Self-esteem.
20
19
18
17
16
15
14
Mean CDI Total Score
Second, the CDI was a good predictor of suicidal
ideation (as measured by the CDI suicidal ideation
item), even when controlling for other known correlates
of suicidal ideation. Interestingly, prediction of suicide
ideation was as good using one CDI sub-scale, Negative
Mood together with the negative predictor Ethnicity
(adolescents with both parents born abroad had less
suicidal ideation) as when using the CDI total score
together with gender, Ethnical origin and MASC total
score.
Also, elevated scores on the CDI were associated with
one common correlate of depression in adolescence,
broken family similarly to previous studies (39, 40) but
not SES (41, 42). Albeit, the association with SES has
not been a ubiquitous one (43).
Thus, we conclude that the CDI has shown some
aspects commonly associated with the validity of a
depression scale. However, the internal consistency
part of our study throws some doubt on the construct
validity of the CDI, particularly the inter-item and the
item-total correlations. This might be due to the
presence of some items that go beyond our present
conception of depression. Possibly, the CDI needs to be
revised. One step might be the cutting down of the CDI
to a shorter scale as suggested by Kovacs (18) in the
current CDI manual. This might be one way of
increasing the validity of the CDI, something that is
needed in view of the conflicting previous findings on the
validity of the CDI (18, 20, 22
24, 38).
There are several qualifications when it comes to the
interpretation of scores obtained with the CDI. First,
this study demonstrated, as have a host of other studies
(4, 5, 33, 36, 44
47), that girls score higher than boys
and that consequently the same score might not have the
same meaning for boys as for girls. However, on the level
of sub-scales, there were fewer gender differences in that
girls and boys did not differ significantly on the CDI
Anhedonia, Interpersonal Problems and Ineffectiveness

13 sub-scales, while girls scored substantially higher on the

12
CDI Negative Mood and on the Negative Self-esteem.
11
10 Thus, a single cut-off score for both genders is not
9 rational. In view of the common finding that roughly 5%
8 of all adolescent girls and roughly 1.5% of adolescent
7
boys in previous studies have had clinical levels of
6
5 depression, something observed both in Swedish (3)
4 and in international studies (10, 33, 48), that the
3 following ‘‘cut-off scores’’ should not be taken too
2
1
literally and that they be put in relation to the task of
0 the assessment. We would suggest, in view of generally
8 9 10 11 12 13 14 15 16 limited sensitivity and specificity previously reported
Age
(18, 22
24; aspects of the validity of the CDI not
Larsson & Melin CDI-total score Girls Boys measured in the current study) that when the CDI is
Fig. 1. Mean CDI scores by age group and gender. Data from used for the screening of depressive symptoms, the cut-
previous study of children by Larsson & Melin (2) are included off scores for the 95th percentile (18 and above) should
for comparison. be used for boys and the cut-off score for the 90th

224 NORD J PSYCHIATRY×VOL 60 ×NO 3 ×2006


percentile (20 or above) be used for girls. However, this
statement must not be taken to imply that the cut-off
score is equivalent with the presence or absence of a
depressive disorder; this must be ascertained with the aid
of clinical interviews. These scores merely imply an
elevated probability of serious levels of depressive
symptoms. Differences in respect to higher CDI total
scores for adolescents from broken homes was statisti-
cally significant but the difference between adolescents
of Swedish and non- Swedish ethnicity failed to reach
statistical significance using the Bonferroni correction
for multiple comparisons. However, these two aspects
need hardly be considered in the interpretation of scores.
The age trends of the CDI indicated increasing scores
(by 0.9) for every year in early adolescence, following the
slower increase in childhood (Fig. 1) as published by
Larsson & Melin (2) and in line with the findings of
Angold (46) and to some extent with Poli (45).
Limitations
The limitations to the current study were those that are
present in the knowledge base of the Swedish translation
of the CDI generally. The lack of clinical data for both
children and adolescents and the lack of structured
interview data in general populations that could be used
to assess the discriminant validity of the CDI are serious
shortcomings in our knowledge of the scale. The current
study is based on the adolescent’s self-report and we had
no independent data to validate any of the adolescent’s
information, nor does the CDI contain any ‘‘social
desirability’’
or ‘‘lie’’
items that can be used to
gauge the extent to which the respondents were reason-
ably truthful in their disclosures. Thus, conclusions as to
the CDI still remain imperfect.
Acknowledgements *We would like to thank the adolescents who
agreed to partake in this study. We would also like to thank Dr Kovacs
for giving us access to the CDI and to Dr March for giving us access to
the MASC.
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Tord Ivarsson, Department of Child & Adolescent Psychiatry,
Göteborg University, Sweden.
Per Svalander, M.Sc., School psychologist, Varberg kommun, Sweden.
Oeystein Litlere, M.Sc., Barn- & Ungdomspsykiatrisk Poliklinikk,
Sentralsjukhuset i Förde, Norway.
NORD J PSYCHIATRY×VOL 60 ×NO 3 ×2006