DEPRESSION AND ANXIETY 22:1119 (2005)

Research Article
HIGH-END SPECIFICITY OF THE CHILDRENS DEPRESSION INVENTORY IN A SAMPLE OF ANXIETY-DISORDERED YOUTH
Jonathan S. Comer, M.A. and Philip C. Kendall, Ph.D.n

Using a receiver operating characteristic (ROC) analysis, the present study investigated the ability of the Childrens Depression Inventory (CDI) to correctly detect depression in a sample of treatment-seeking anxious youth (N 44). The ADIS-C/P was used to determine diagnostic status of participants. Anxious children who met diagnostic criteria for a depressive disorder scored higher on the CDI than anxious children who did not meet criteria for a depressive disorder, supporting the CDI as a continuous measure of depressive symptomatology. In contrast, with regard to detecting a depressive disorder, CDI cut scores did not achieve favorable values across diagnostic utility indices (including the cut score of 13 that has been recommended). These findings support the CDI as a continuous measure of depressive symptoms, but do not support the CDI as a sole assessment for a diagnosis of depression within a sample of anxiety-disordered youth. Depression and Anxiety 22:1119, 2005. & 2005 Wiley-Liss, Inc. Key words: child; depression; diagnosis; assessment; anxiety; childhood depression; childhood anxiety; specificity; self-report

Given the high prevalence and considerable impact of

depressive disorders in youth [Brent and Birmaher, 2002; Costello et al., 2003; Garber and Horowitz, 2002; Sanchez and Le, 2001] as well as the persistence into adulthood of functional impairment associated with childhood and adolescent depression [e.g., Lewinsohn et al., 2003], the evaluation of assessments used to detect depressive symptomatology is critical. The past two decades have seen a great increase in the use of brief self-rating scales in the assessment of childhood depressive symptomatology [see Myers and Winters, 2002; Silverman and Rabian, 1999]. Scores can be compared to those of normative samples to determine the extent to which reported symptomatology is atypical. Relative to clinical interviews, such measures are both time and cost efficient [Hart and Lahey, 1999]. The Childrens Depression Inventory (CDI) [Kovacs, 1981, 1992] is one of the most widely used depressive symptomatology self-rating scales for children. Consisting of 27 self-report items, the CDI was modeled after the Beck Depression Inventory (BDI) [Beck, 1972; Beck et al., 1961] to assess affective, cognitive, and behavioral symptoms of depression in

youth. The CDI has demonstrated excellent reliability [e.g., Finch et al., 1985], and broadly speaking, the CDI has demonstrated an adequate ability to distinguish between clinical and nonclinical groups of children [e.g., Fristad et al., 1987; Saylor et al., 1984]. For example, Saylor et al. [1984] compared the CDI scores of psychiatric inpatients who manifested various clinical disorders to those of community schoolchildren and reported that the inpatient group scored significantly higher. Less clear, however, is the CDIs ability to distinguish between children with depressive
Child and Adolescent Anxiety Disorders Clinic, Department of Psychology, Temple University, Philadelphia, Pennsylvania Contract grant sponsor: NIMH
n

Correspondence to: P.C. Kendall, Department of Psychology, Weiss Hall, Temple University, Philadelphia, PA 19122. E-mail: pkendall@temple.edu Received for publication 13 August 2004; Revised 5 February 2005; Accepted 16 March 2005 DOI: 10.1002/da.20059 Published online 17 June 2005 in Wiley InterScience (www. interscience.wiley.com).

& 2005 WILEY-LISS, INC.

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disorders and children who display other kinds of clinical problems [for a review, see Silverman and Rabian, 1999]. Some studies have found that children with depressive disorders score significantly higher on the CDI than nondepressed clinical samples [e.g., Haley et al., 1985; Hodges, 1990; McCauley et al., 1988; Timbremont et al., 2004] whereas other studies have reported no differences between the CDI scores of depressed and nondepressed clinical samples [e.g., Kazdin, 1987; Kazdin et al., 1983; Saylor et al., 1984]. Such discrepant findings may be due to any of several issues. First, discrepant methodologies were employed. In Haley et al. [1985], Kazdin [1987], and Saylor et al. [1984], diagnoses were assigned without the use of a formal structured interview. In contrast, Hodges [1990], McCauley et al. [1988], and Timbremont et al. [2004] used structured interviews to determine diagnostic status. Consequently, the reliability of the diagnostic groups likely varies across these studies. Second, the comparison groups used in these studies often dif fered from one another in important ways. The majority of studies employed heterogeneous comparison groups (e.g., nondepressed psychiatric inpatients presenting with any of a number of clinical problems), and the composition of these heterogeneous comparison groups differed from study to study. For example, Haley et al.s [1985] comparison group consisted of 45% conduct-disordered children, 30% adjustment-disordered children, 20% anxious children, and 5% ADHD children. In contrast, McCauley et al.s [1988] comparison group consisted of 15% conductdisordered children, 20% adjustment-disordered children, 32% anxious children, 6% ADHD children, and 23% children with clinical problems not included in the Haley et al. [1985] study. Correct diagnosis of depression among youth presenting with anxiety disorders is important. This need is underscored by research suggesting that individuals presenting with comorbid anxiety disorders and major depression exhibit more severe forms of psychopathology and are more symptomatic than individuals presenting with pure (i.e., noncomorbid) depression or anxiety. Such patients present with greater levels of dysfunction, hypersomnia, agitation, weight disturbance, premature treatment termination, and suicidality [e.g., Brady and Kendall, 1992; Brown et al., 1996; Dunner, 2001; Kendall and Brady, 1995; Kessler et al., 1999; Mitchell et al., 1988]. Anxious youth presenting with comorbid depression report greater anxious symptomatology than anxious youth without comorbid depression [e.g., Bernstein, 1991], may evidence less favorable response to exposure-based treatments [Berman et al., 2000], and have a poorer long-term prognosis in the domains of occupational functioning and mental health needs [e.g., Last et al., 1987; Manassis and Menna, 1999]. In the child anxiety treatment outcome literature, the CDI is perhaps the most commonly used self-rating scale used to detect depressive symptomatology [e.g.,

Barrett et al., 2001; Kendall et al., 1997; Manassis et al., 2002]. Given the increased adversity associated with comorbid depression in such youth [e.g., Manassis and Menna, 1999] and the instruments widespread use in anxious child populations, examining the CDIs ability to detect depression among anxious youth is critical. There is evidence to suggest that depressed youth without comorbid anxiety disorders score significantly higher on the CDI than anxious youth without comorbid depressive disorders [Hodges, 1990]. Timbremont et al. [2004] employed logistic regression to determine whether the CDI differentiates depressive disorders from anxiety disorders. Although they found the CDI to successfully discriminate between the two sets of disorders, children with anxiety disorders comprised only 2% of their sample, preventing a rigorous examination of the issue. Neither Hodges [1990] nor Timbremont et al. [2004] addressed the issue of comorbid depression and anxiety disorders. To date, no study has explored the extent to which the CDI can detect depression among youth presenting with an anxiety disorder. The importance of reevaluating the psychometric properties of self-rating scales when they are used in samples dif ferent from the ones for which they were developed has been documented [Coles et al., 2001; Kazdin, 1998]. The present study examined the performance of the CDI in detecting depression within a sample of treatment-seeking anxious youth, and was conducted with the broader goal to examine the CDIs high-end specificity [i.e., the extent to which high scores of a depression scale are associated solely with increased levels of depression and not with other disorders; Kendall et al., 1987]. The use of a comparison group composed largely of externalizing children [e.g., Haley et al., 1985] provides some information regarding the CDIs specificity, but a more rigorous evaluation would evaluate the CDIs ability to distinguish depressed children within a sample of youth presenting with neighboring (i.e., internalizing) disorders. It has been argued that the most informative such sample would be one composed of individuals suffering from anxiety disorders [Kendall et al., 1987; Sloan et al., 2002], given the syndromal overlappings of depression and anxiety in youth [e.g., Axelson and Birmaher, 2001; Chorpita, 2002] as well as the high comorbidity of clinical anxiety and depression in youth [see Brady and Kendall, 1992; Last et al., 1987]. Thus, in addition to examining the CDIs performance in detecting depression in a clinical sample of anxious youth, the present study also was designed to examine the high-end specificity of the CDI. Using a receiver operating characteristic (ROC) analysis, the present study investigated the CDIs ability to correctly distinguish treatment-seeking anxious youth with and without depression. Six questions were addressed: (a) Do children diagnosed anxious and depressed (Anx+Dep) score higher on the CDI than children diagnosed with an anxiety disorder (Anx)? (b)

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What is the overall utility of the CDI in distinguishing these two groups across all potential cut scores? (c) At each potential cut score, what are the estimates of sensitivity (i.e., percentage of anxious children meeting diagnostic criteria for a depressive disorder correctly identified by the CDI as depressed) and specificity (i.e., percentage of anxious children not meeting diagnostic criteria for a depressive disorder correctly identified by the CDI as nondepressed)? (d) At each potential cut score, what are the estimates of positive predictive power (PPP; i.e., the percentage of anxious children classified by the CDI as depressed who actually meet criteria for a depressive disorder) and negative predictive power (NPP; i.e., the percentage of anxious children classified by the CDI as nondepressed who in actuality did not meet criteria for a depressive disorder)? (e) Across these indices of utility, how does a cut score of 13 (recommended by Kovacs for clinical samples) fare? (f) Is there an optimal cut score for detecting diagnosed depression in youth with a diagnosed anxiety disorder?

SUBJECTS AND METHODS

PARTICIPANTS Participants included 44 children (25 boys) seeking treatment at the Child and Adolescent Anxiety Disorders Clinic at Temple University and their parents (44 mothers, 39 fathers). Children ranged in age from 7 to 14 years (M 10.3, SD 1.80). Participants were drawn from a sample of 100 consecutive clinic admissions who met criteria for an anxiety disorder (determined via parentchild composite diagnostic profiles generated by the Anxiety Disorders Interview Schedule for Children (ADISC/P) [Silverman and Albano, 1996]. Within this sample, 20 children also met criteria for a depressive disorder (i.e., major depression or dysthymic disorder). To produce groups that were of comparable size, comparison children (n 24) were randomly selected from the remaining 80 youths. All participating children met criteria for a principal diagnosis of generalized anxiety disorder (n 20), separation anxiety disorder (n 11), or social anxiety disorder (n 13). Comorbid conditions were included. Criteria for exclusion were very few: use of anti-anxiety medication, child IQ below 80, and psychotic symptoms. The majority of the sample was Caucasian (81.82%); the remainder of the sample was African American (11.36%) or Other (6.82%; see Table 1). Most participants (n 36) came from two-parent families. Regarding annual financial income, 18.18% of the sample earned less than $40,000; 20.45% earned between $40,000 and $59,999; 29.55% earned between $60,000 and $79,000; and 31.82% earned more than $80,000. Participating children were parent-, school-, or pediatrician-referred to the clinic via media advertisements or school-based outreach ef forts.

MEASURES Anxiety Disorders Interview Schedule for Children (ADIS-C/P) [Silverman and Albano, 1996]. The ADIS-C/P is a semistructured diagnostic interview that assesses child psychopathology within the framework of the DSM-IV [American Psychiatric Association, 1994], with particular coverage of the internalizing disorders. The ADIS-C (child version) and the ADIS-P (parent version) were used to collect data on child and parent reports of the childs symptomatology. The ADIS-C/P has demonstrated strong concurrent validity [Wood et al., 2002] and is sensitive to changes related to treatment [Kendall et al., 1997; Silverman et al., 1999]. In age ranges comparable to the present sample, the interview has demonstrated excellent retest reliability [k4.70 for both versions; Silverman et al., 2001] and good overall interrater reliability [k .76 for ADIS-C; k .67 for ADIS-C; Silverman and Eisen, 1992; Silverman and Rabian, 1995]. Childrens Depression Inventory (CDI) [Kovacs, 1992]. The CDI is a widely used self-rating scale of depressive symptomatology in children [Silverman and Rabian, 1999]. For each item, the child is asked to endorse one of three statements that best describes how he or she has typically felt over the past 2 weeks (e.g., I am sad once in a while, I am sad many times, or I am sad all the time). Each response is scored as either 0 (asymptomatic), 1 (somewhat symptomatic), or 2 (clinically symptomatic), contributing to an overall CDI score that can range from 0 to 54. The scale has demonstrated excellent internal consistency in both clinical and nonclinical samples [a4.80; Finch et al., 1985; Ollendick and Yule, 1990; Smucker et al., 1986] and acceptable test-retest reliability identified in both clinical and nonclinical samples [Finch et al., 1987; Kazdin, 1987; Kovacs, 1992; Nelson and Politano, 1990]. PROCEDURE At intake, all 100 initial consecutive cases were administered the ADIS-C/P. Informed parental consent and child assent were obtained, and separate diagnosticians conducted interviews with the participating children and their parents. In most cases, both parents were present during the parent-report interview (n 39). Diagnosticians (n 15) were doctoral students specializing in child/adolescent clinical psychology. After structured training, diagnosticians each watched seven videotaped ADIS-C/P interviews conducted by other diagnosticians in the study and constructed independent diagnostic profiles. Evaluation of agreement among diagnosticians on these profiles revealed high interrater reliability for both interviews (k4.75). Yearly reliability checks employing this same methodology indicated that interrater reliability was maintained (k4.75) throughout the study. Such reliability is comparable to that identified in

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previous work with the ADIS-C/P [Silverman and Eisen, 1992; Silverman and Rabian, 1995]. For each child, separate diagnosticians conducted the parent and child interviews. To control for any potential diagnostician bias, diagnosticians each conducted an approximately equal number of parent and child interviews. Parent and child diagnosticians reviewed the reports from their respective interviews and independently assigned diagnoses. Composite diagnostic profiles were generated for each child by integrating the independent parent and child interviews using the or rule [standard practice in the integration of parent and child diagnostic reports; see Silverman and Albano, 1996; see also Comer and Kendall, 2004]. That is, a disorder was considered present in the childs composite diagnostic profile if either the child report or the parent report yielded a diagnosis of the disorder. From the composite diagnoses, two groups of children were generated: an Anx+Dep group consisting of all children meeting criteria for an anxiety disorder and a depressive disorder (n 20), and an Anx group consisting of children who met criteria for an anxiety disorder, but not for a depressive disorder (n 24; sampled randomly from the remaining 80 clinic children presenting to produce a comparison group that was of comparable size). As is typical [Verduin and Kendall, 2003; see also Comer et al., 2004], comorbidity among the anxiety disorders was high, with over 90% of the participants meeting criteria for at least two diagnoses. All children completed the CDI on a computer, with a recorded voice reading the items aloud while the child could read along on the screen. For each child, a clinic staff member remained in the room to answer questions, to provide support in the event of distress, or both. DATA ANALYSIS Demographic differences between the two groups were examined using t tests and chi-square analyses. To determine the overall utility of the CDI in distinguishing Anx+Dep and Anx children, ROC analysis was used. ROC analysis provides a depiction of an instruments accuracy by demonstrating the limits of the instruments ability to discriminate over the complete spectrum of cut scores [for a review of ROC analysis, see Zweig and Campbell, 1993]. Sensitivity at each potential cut score was operationalized as the percentage of anxious children meeting diagnostic criteria for a depressive disorder (according to the ADIS-C/P) who were correctly identified by the CDI as depressed. Specificity at each potential cut score was operationalized as the percentage of anxious children not meeting diagnostic criteria for a depressive disorder (according to the ADIS-C/P) who were correctly identified by the CDI as nondepressed. Plotting all of the sensitivities and corresponding specificities at a each particular cut score provides a

curve, the area under which ranges from 1.0 (perfect separation of test scores of the two groups) to .5 (no apparent distributional dif ference between the two groups of test scores). This area under the curve (AUC) provides a quantitative estimate of diagnostic accuracy and, consequently, the overall utility of the CDI (across all cut scores) in distinguishing children with diagnosed anxiety and depression from children with only diagnosed anxiety. To determine the PPP of the CDI at each potential cut score, we calculated the percentage of anxious children classified by the CDI as depressed who actually met criteria for a depressive disorder. To determine the NPP of the CDI at each potential cut score, we calculated the percentage of anxious children classified by the CDI as nondepressed who did not meet criteria for a depressive disorder. Estimates of PPP and NPP are af fected by the prevalence of children classified as depressed by the CDI at each cut score in a given sample. Consequently, base rates of children classified by the CDI as depressed are reported for each cut score to enhance interpretation of PPP and NPP estimates. Additionally, kappa coef ficients, indicating agreement between CDI and ADIS-C/P classifications after correcting for chance [Cohen, 1960] are reported as they provide further indication of the diagnostic utility of the CDI at each cut score after correcting for base rates. For further descriptive purposes, the overall correct classification rate (percentage of cases classified by the CDI in accordance with ADIS-C/P, either depressed or nondepressed) was computed for each potential cut score. These various indices were examined to determine the utility of employing the recommended cut score of 13 (for clinical samples) as well as the utility of employing other potential cut scores to identify depressive disorder in the present sample. The sample size provides sufficient power with which to conduct the present analyses.

RESULTS
Table 1 presents the demographic characteristics of Anx+Dep and Anx children. Analyses determined that the two groups did not dif fer according to age, gender, or ethnicity (see Table 1). Table 2 presents the means, standard deviations, and ranges of CDI scores. Anx+Dep children scored significantly higher on the CDI than Anx children (see Table 2). Figure 1 presents the ROC curve generated by plotting all of the sensitivities and corresponding 1specificities at each potential CDI cut score. Across the entire range of cut scores, the CDI demonstrated acceptable overall utility in distinguishing true positives from true negatives (AUC .834, SD .059). This AUC significantly differs from .5, or the null value that would indicate no apparent distributional difference between the two groups on CDI scores (P o.001).

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TABLE 1. Demographic characteristics of children in Anx+Depn and Anxnn

Anx+Dep (n 20) Age (yr), mean (SD) Gender (% female)b Ethnicity (%)c Caucasian AfricanAmerican Other
a

Anx (n 24) 10.16 (1.79) 41.57 83.33 12.50 4.17

10.46 (1.85) 45 80 10 10

n Anx+Dep refers to children meeting diagnostic criteria for both an anxiety and a depressive disorder. nn Anx refers to children meeting diagnostic criteria for an anxiety disorder, but not for a depressive disorder. a Anx+Dep and Anx do not differ according to age [t(42) .538; P .59]. b Anx+Dep and Anx do not differ according to gender [w2(1) .049; P .82]. c Anx+Dep and Anx do not differ according to ethnicity [w2(2) .619; P .73].

TABLE 2. CDI Scores of Anx+Depn and Anxnn

Score Mean (SD) Minimum Maximum Anx+Dep (n 20) 16.25 (6.90) 6 30 Anx (n 24) 7.71 (4.86) 0 18

Figure 1. ROC plot of sensitivities and 1-specificities for each potential CDI cut score.

Anx+Dep children scored significantly higher than did Anx children (t(42) 4.81; Po.0001). n Anx+Dep refers to children meeting diagnostic criteria for both an anxiety and a depressive disorder. nn Anx refers to children meeting diagnostic criteria for an anxiety disorder, but not for a depressive disorder.

Analysis of the area under the ROC curve allows us to determine the overall utility of the CDI in distinguishing Anx+Dep from Anx children across all scores, but does not provide indication of the diagnostic utility of the CDI at each potential cut score. Table 3 presents the sensitivity, specificity, PPP, and NPP for each potential CDI cut score. Base rates, kappa coefficients, and the overall correct classification rates corresponding to each cut score also are reported. As the cut score increases, the percentage of anxious children meeting criteria for a depressive disorder who were correctly identified by the CDI as depressed (i.e., sensitivity) decreases, with indices ranging from .950 (when employing a cut score of 7) to .200 (when employing a cut score of 23). Alternatively, the percentage of anxious children not meeting criteria for a depressive disorder who were correctly identified by the CDI as nondepressed (i.e., specificity) increases as the cut score increases, with indices ranging from .417 (when employing a cut score of 7) to 1.00 (when employing cut scores of 1923).

As presented in Table 3, PPP estimates ranged from .576 (CDI cut score of 7) to 1.00 (CDI cut scores of 1922). NPP estimates ranged from .600 (when a CDI cut score of 23 was employed) to .909 (CDI cut score of 7). As mentioned earlier, estimates of PPP and NPP are affected by the base rate of children classified as depressed by the CDI at each cut score. Consequently, base rates are reported to enhance interpretation of PPP and NPP estimates. Not surprisingly, the base rate of anxious children classified as depressed by the CDI decreases as the employed cut score increases. Base rates ranged from 75.5% of the overall sample classified as depressed (when employing a cut score of 7) to 9.1% of the overall sample classified as depressed (when employing a cut score of 23). The highest agreement between ADIS-C/P and CDI classification (after correcting for base rates) was obtained with a CDI cut score of 10 (k .553); the lowest agreement (after correcting for base rates) was obtained with a CDI cut score of 23 (k .214).

DISCUSSION
In the present sample, higher CDI scores were associated with the presence of a depressive disorder. Consistent with previous research [e.g., Hodges, 1990; Timbremont et al., 2004], depressed children scored higher on the CDI than children who only met diagnostic criteria for an anxiety disorder, supporting the use of the CDI as a continuous measure of depressive symptomatology with treatment-seeking anxious youth.

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TABLE 3. Diagnostic utility of the CDI

CDI cut score 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 Sensitivity .200 .300 .350 .400 .400 .400 .400 .500 .500 .500 .550 .700 .750 .900 .900 .900 .950 Specificity 1.000 1.000 1.000 1.000 1.000 .958 .958 .958 .917 .917 .833 .708 .667 .667 .542 .542 .417 PPP 1.000 1.000 1.000 1.000 1.000 .889 .889 .901 .833 .846 .733 .667 .652 .692 .621 .621 .576 NPP .600 .632 .649 .667 .667 .657 .657 .697 .688 .710 .690 .739 .762 .889 .867 .867 .909 Base rate .091 .136 .136 .182 .182 .205 .205 .250 .273 .295 .341 .477 .523 .591 .659 .659 .750 k .214 .319 .370 .421 .421 .376 .376 .476 .431 .481 .391 .407 .412 .553 .426 .426 .348 OCC .240 .682 .705 .727 .727 .705 .705 .750 .727 .750 .705 .705 .705 .773 .705 .705 .659

CDI, Childrens Depression Inventory; PPP, Positive Predictive Power; NPP, Negative Predictive Power; Base rate, percentage scoring at or above cut score; k, agreement between CDI and ADIS-C/P after correcting for chance; OCC, Overall Correct Classification.

In contrast, the present findings did not support the use of the CDI as a categorical measure of depressive disorder with treatment-seeking anxious youth. Despite demonstrating acceptable overall utility in distinguishing true positives from true negatives in the present sample, the identified AUC of .83 falls between that of chance (.50) and maximum discrimination (1.0). Thus, consistent with Sloan et al.s [2002] ROC analysis of the high-end specificity of the BDI in anxious adults (AUC .77), the CDI did not approach maximum utility in distinguishing anxious youth with comorbid depression from anxious youth without comorbid depression. Examination of the sensitivity and specificity indices for the CDI at each cut score provided further evidence against the use of the measure in a categorical fashion with treatment-seeking anxious youth. As the cut score increased, the CDIs sensitivity (i.e., percentage of anxious children with a depressive disorder who were correctly identified by the CDI as depressed) decreased. Alternatively, as the CDI cut score employed increased, specificity (i.e., percentage of nondepressed anxious children who were correctly identified by the CDI as nondepressed) increased. Given this inverse relationship, determining the optimal cut score for CDI with anxious youth involves achieving a favorable balance between these diagnostic utility indices. Matthey and Petrovski [2002] suggested that sensitivity of .70 and specificity of .80 are needed for a worthwhile cut score. Such a cut score would allow for at least 70% of actually depressed cases to be correctly classified while ensuring that at least 80% of nondepressed cases are correctly classified. As seen in Table 3, in the present sample of anxious youth, no CDI cut score achieved this criterion.

Because a cut score of 13 has been recommended for clinic samples [see Kovacs, 1992], we examined it specifically. The cut score did not achieve the sensitivity/specificity criterion of .70/.80 suggested by Matthey and Petrovski [2002]. Employing the recommended cut score achieved a specificity value of .83, but sensitivity was only .55, indicating that only 55% of diagnosed depressed children were correctly classified as depressed by the CDI. Further, when employing the recommended cut score, 26.7% of those classified by the CDI as depressed did not meet criteria for a depressive disorder, and 31% of those classified by the CDI as nondepressed actually met criteria for a depressive disorder. At this cut score, there also was only 39.1% correspondence between CDI classification and actual diagnosis of depressive disorder after controlling for chance. Referred to as targeted or prescriptive treatment [e.g., Beutler and Clarkin, 1990], determining an indicated treatment course for a given child is not a simple undertaking for comorbid cases. For cases of comorbid depression and anxiety in youth, Kendall et al. [1992] suggested that treatment requires the flexible synthesis of treatment components that have demonstrated utility in the treatment of each separate disorder. As Clarkin and Kendall [1992] noted, comorbid conditions may not need to be treated concurrently, and the merits of a sequence of treatments for comorbid internalizing disorders have been highlighted elsewhere in the literature [e.g., Comer et al., 2004]. Failing to detect the presence of major depression in a child presenting with an anxiety disorder could substantially limit the prescribed treatment program, as empirically supported treatments for childhood anxiety disorders [e.g., Kendall et al., 1997] do not

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target many of the depressive symptoms of major depressive disorder [e.g., Jolly and Dykman, 1994; Schniering and Rapee, 2004]. The present findings argue against the use of the CDI with anxious youth as a categorical measure of depression, and thus should be not be used as a sole assessment of depression when planning treatment for anxious youth. Such findings are consistent with previous recommendations [e.g., Fristad et al., 1997; Kendall and colleagues, 1987; 1995] against the use brief self-report measures in the absence of structured diagnostic interviews. Note that the present findings were obtained using a sample of youth presenting for treatment of anxiety, and thus are not necessarily generalizable to other populations. As documented elsewhere [e.g., Berkson, 1946; Du Fort et al., 1993], in clinical research there can be a selection bias, in which individuals suffering from multiple disorders are more likely to present for treatment than individuals suffering from only one disorder. Thus, the present findings merit replication in community samples. Also note that the present sample consisted of youth presenting for treatment at a university-based clinic. Previous work has found that anxious youth presenting for treatment at university clinics, as opposed to community-based clinics, were less likely to come from low-income and single-parent homes [e.g., Southam-Gerow et al., 2003]. The present sample, predominantly Caucasian, limits the generalizability of the findings to similar groups. Moreover, the present study was designed to provide indication of the high-end specificity of the CDI, or the extent to which high scores are associated solely with increased levels of depression and not with other diagnoses. Although the CDI was not designed for categorical classification, the literature does include work using the measure in this manner [e.g., Almqvist et al., 1999; Donnelly, 1995; Nolen-Hoeksema et al., 1986; Timbremont and Braet, 2004; for a review, see Fristad et al., 1997]. In fact, a number of studies have solely employed the CDI in screening for the presence or absence of depression [e.g., Donnelly, 1995; Masi et al., 2000; Nolen-Hoeksema et al., 1986; Timbremont and Braet, 2004; Verdeli et al., 2004; for reviews, see also Fristad et al., 1997; Matthey and Petrovski, 2002]. Despite the appeal of expediency, the use of a brief self-report instrument to diagnose children (in the absence of a structured diagnostic interview) may be misguidedFespecially in the absence of documentation that the instrument distinguishes among diagnostic groups. As previously mentioned, investigations have yielded mixed results regarding the CDIs ability to distinguish among various child populations [for a review, see Silverman and Rabian, 1999]. The majority of these investigations have employed heterogeneous comparison groups (e.g., nondepressed psychiatric inpatients presenting with any of a number of clinical problems). Kazdin [1987], for example, compared the scores of clinically depressed children to those of a

group composed of over 50% conduct-disordered children. In fact, the majority of CDI specificity studies have compared the CDI scores of depressed children to those in samples of children mostly presenting with externalizing problems [e.g., Haley et al., 1985]. The use of such heterogeneous comparison groups can, depending on the diagnostic breakdown of such groups, limit the extent to which highend specificity is actually being investigated. With the syndromal proximity of depression and anxiety [Axelson and Birmaher, 2001; Kendall and Brady, 1995], exploring a scales ability to detect depression among patients presenting with an anxiety disorder permits a rigorous investigation of the measures high-end specificity [see Sloan et al., 2002]. The present sample was composed of treatmentseeking children with an anxiety disorder, a group characterized by high negative af fectivity [Axelson and Birmaher, 2001; Chorpita, 2002]. Accordingly, though potentially limited to the sample, the present findings indicate that the CDI does not demonstrate adequate high-end specificity. That is, high scores on the CDI may not be solely related with increased levels of depression but rather with increased levels of anxiety and depression (negative affectivity) more broadly.

ACKNOWLEDGMENTS
This study was supported in part by the NIMH (MH59087). We thank J. Hambrick, A. Angelosante, S. Aschenbrand, and S. Nath for their helpful comments.

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