The youth interview is critical because parents and teachers tend to underreport depressive symptoms.3 Clinicians differ in their view about how this should be achieved; some prefer seeing adolescents first and then together with the parents—or parents alone, if one expects too much conflict. For children, the opposite is often preferred: to see the child together with parents or parents alone first, and then interviewing the child alone. Children are less likely to answer questions reliably about mood, time concepts, comparing themselves to their peers, and questions that require the child to use judgment.4 Interviewing the parent first allows the eliciting of relevant information and the time course of symptoms, which can be used later when interviewing the child.5 For example, the interviewer can start by stating that parents have described periods when the child looks sad or angry, and asking the child to describe the feelings during these times, or having the child point to a face on a chart with a variety of expressions/emotions. This can help children with chronological data (e.g., “your parents said you have been sad since the New Year” rather than “tell me about your moods over the last 2 months.”). Questions need to be simple (e.g., dealing with one concrete issue at a time: “Have you been feeling so bad that you have been crying often in the last few days?”), not long or complicated (e.g., several issues in one question: “Have you been feeling sad, having problems sleeping, or not concentrating at school?”). Avoid leading questions (more likely to draw “yes” answers and more false positives) and vague, open-ended questions (more likely to draw “I don’t know” answers and more false negatives).

Many adolescents prefer to be interviewed alone first. Adolescents value their privacy and independence and are more likely to share information if they know it will be kept confidential.
Clinicians should outline the parameters by which they will share information with the parents, which mainly includes safety issues, such as suicidal and homicidal thoughts. The youth should also be made aware that disclosures of abuse will result in a call to local child protective services. Contrary to popular views, asking about suicide will not induce or trigger the youth to commit suicide. Young persons are often relieved when a caring clinician asks about their suicidal thoughts.

Gaining the trust of depressed young persons is often a challenge; however, without trust, valid information is less likely to be obtained. Apathy (“sure, whatever”) and withdrawal (no eye contact, no talking) are common responses. Starting with favorite hobbies or pleasurable topics is often helpful to get the young person talking. Finding a common interest between clinician and young person is even better, with care not to overdo it.

Parents can be interviewed alone if sensitive information needs to be discussed. The interview with the parents should focus on the patient’s depressive and other symptoms, antecedent triggers, school and social functioning, and family history. Opening a “Pandora’s box” is not the goal of an initial assessment.

After the interviews with the patient and family, if the case is difficult or complex, it may be helpful to debrief with a colleague. It is useful to spend some time processing the information, considering the differential diagnoses and treatment, and scoring rating scales. Once a provisional diagnosis and treatment plan are formulated, the clinician can debrief the patient and parents. Psychoeducation is often the focus at this stage because the family usually has questions regarding diagnoses, prognosis, and treatment.

Many instances arise when youth give opposite information to their parents. Further inconsistencies can come from other sources, such as teachers, friends, and medical records. Basically the clinician needs to meet together with the child and parent(s) and in a nonjudgmental way resolve discrepancies. Clinicians can also use either the “best-estimate diagnoses” or the “or” rule to reconcile differences.

The best estimate diagnosis is the process by which clinicians synthesize all available data, resolve discrepancies between data sources, and use their clinical judgment to arrive at the final diagnosis.6 Using guidelines to resolve discrepancies between data sources results in good to excellent test-retest reliability. These include the following:7

Another method to resolve discrepancies is the “or” rule, where a symptom is counted toward the criteria if either the parent or youth endorses the symptom. The “or” rule maximizes sensitivity at the cost of specificity8 and may be useful in cases in which young persons minimize symptoms. However, this method may result in an increase in the number of comorbid diagnoses.

Detecting depression can be difficult because depressed youth are often dismissed as having problems related to bad behavior, or their behavior is attributed to a “phase” of development such as adolescent angst. Table 3.1 outlines common presentations.

Mnemonics, such as SIGECAPS, are helpful to remember the DSM-IV criteria for mood disorders. Table 3.2 lists what each letter of the mnemonic stands for and examples of developmentally-appropriate questions to elucidate each symptom.10

To meet DSM-IV criteria for a major depressive episode, at least five out of the nine symptoms should have been present for at least 2 weeks; one of the symptoms being either depressed mood or anhedonia (loss of interest or pleasure). Except for depressed mood, the other criteria for a major depressive episode are contained in the mnemonic SIGECAPS.

It is important to assess the current (or most recent) depressive episode as well as prior depressive episodes, and to evaluate their severity (Table 3.3). This is important because treatment for a single episode differs from that of recurrent depression, and treatment for mild to moderate depression is different from severe depression. Mood charts (see Resources for Families section) can be helpful to map out depressive episodes, illustrating frequency or number of episodes, triggers, duration, and severity.

Episodicity is a critical characteristic of subjects with mood disorders, although a minority may have chronic symptoms (see Chapter 1). However, a common error is to make a diagnosis of “major depressive episode.” The correct diagnosis is “major depressive disorder,” single or recurrent episode, and mild, moderate, or severe.

Dysthymic disorder is diagnosed using the same mnemonic for depression, except that the last two criteria (psychomotor agitation/retardation and suicidality) are not used (Table 3.4).

For dysthymia, the child or adolescent shows depressed mood or irritability for most of the day, more days than not, and for 1 year at least. In addition, the young person ought to have at least two of the symptoms in Table 3.4. It is also required not to have been without depressive symptoms for >2 months at a time and not to have had a major depressive episode during that year. The following is a case vignette of dysthymic disorder in an adolescent: