Assessment of Behavioral Distress and Depression in a Pediatric Population

Using a multitrait—multimethod approach, measures designed to assess emotional distress in medical populations were compared with depression measures standardized on healthy children. In a hospitalized sample of children ages 4 to 12 years old, parent ratings of child distress were compared to nurse ratings and children's responses to a pictorial measure. An assessment battery was administered to 70 mothers and children; 32 nurse ratings were also obtained. Results indicated overlap between information obtained from measures of depression and pediatric-specific measures of distress. However, the findings provide some evidence that measures that incorporate the pediatric context in assessment may be more suitable for medically ill children. Children's reactions to medical intervention vary considerably, but emotional distress during hospitalization is typical. In a pediatric context, emotional distress may be manifest as affective symptoms of depression (e.g., dysphoria, irritability) and behavioral signs of distress (e.g., social withdrawal, agitation, anxiety). Such distress can interfere with medical procedures, and research has historically demonstrated that without intervention during their stay, children display more long-term emotional and behavioral problems following hospitalization (e.g., Douglas, 1975; Melamed & Siegel, 1975). A review of studies utilizing diagnostic criteria indicated that as many as 40% of children in pediatric settings exhibit depressive symptoms (Finch & Saylor, 1984). An early study of 7to 12-year-old children found that 38% exhibited dysphoric mood during hospitalization, based on semistructured interviews of the parent and child (Kashani, Barbero, & Bolander, 1981). An examination of referral questions provided to a pediatric psychology service on inpatient children in a children's hospital found that 19% of consultations were referred for depression or suicide attempts, and 12% of consultations were referred for adjustment to chronic illness (Olson et al., 1988). A review of the effects of hospitalization and surgery on children estimated that at least 20% of children experience emotional as well as behavioral difficulties (Yap, 1988). Focusing on behavioral manifestations of distress, parent ratings of child behavioral upset during hospitalization have been found to be significantly higher than ratings of child distress at home (Rodriguez & Boggs, 1994). Younger pediatric patients also appear even more likely to display emotional distress than older children (Jay, Ozolins, Elliott, & Caldwell, 1983; Saylor et al., 1987; Yap, 1988). The variable findings regarding the prevalence of emotional distress in medically ill children may be attributable to variability in the definition and presentation of emotional distress, or to differences in assessment or in the incidence of distress associated with distinct medical groups (Kashani & Breedlove, 1994). Obstacles in assessment complicate the study of emotional distress in pediatric samples. Few measures appropriate for use with hospitalized children are available. When requested to assess a child's emotional distress in a pediatric setting, psychologists have often been forced to turn to standard measures of depression. Such decisions are problematic for two reasons: Measures of depression are not necessarily applicable to pediatric populations, and measures of depressive symptomatology do not adequately assess behavioral indicators of distress. The solution is more complicated than simply standardizing such traditional measures on pediatric samples, because such a strategy would not resolve the problem that the measures often incorporate items inappropriate for ill children. For example, the Children's Depression Inventory (CDI; Kovacs, 1983) has been frequently administered to pediatric populations as a measure of depressive symptomatology (e.g., Eason, Finch, Brasted, & Saylor, 1985; Saylor, Finch, & McIntosh, 1988). Yet the CDI includes items pertaining to school behavior that may be irrelevant during hospitalization as well as items assessing vegetative signs of depression, which may be confounded by the child's medical illness. Indeed, one study of pediatric cancer patients suggests that a structured interview of depression designed for healthy children is confounded by features of medical illness because of significant overlap between depressive symptoms and the degree of impairment due to medical illness (Heilgenstein & Jacobsen, 1988). Therefore, measures of depression that have been standardized using healthy children may artificially inflate estimates of emotional distress or depression in pediatric samples. Because such measures of depression are not suitable, researchers in pediatric psychology have developed alternative research instruments to evaluate emotional distress. One measure designed for pediatric populations, the Observational Scale of Behavioral Distress (Jay & Elliott, 1986; Jay et al., 1983), assesses behaviors indicative of anxiety and pain in cancer patients. Similarly, another observational pain-rating scale for children ages 2 through 6 includes some "depression-like" items (Gauvain-Piquard, Rodary, Rezvani, & Lemerle, 1987, p. 179). However, both observational rating scales were based on cancer patients, and both scales emphasize pain behavior rather than emotional distress. Moreover, the complex nature of observational measures results in such scales being used primarily in research rather than clinical practice. In contrast, the Behavioral Upset in Medical Patients Revised (BUMP-R; Saylor et al., 1987) appears more promising for pediatric samples (see Rodriguez & Boggs, 1994) as a parent-report measure targeting behavioral manifestations of emotional distress designed for hospitalized children with diverse medical diagnoses. Measures specifically developed for pediatric samples have not yet been directly compared with measures designed to evaluate depression in healthy children. Using a multitrait—multimethod approach, this investigation addressed these issues. This study involved the assessment of emotional distress in a sample of 4to 12-year-old hospitalized children, including the 4to 8-year-old age group because younger children are less often studied but may be at higher risk. Specifically, parent and nurse reports on a pediatric-specific measure (i.e., the BUMP-R) were compared to parent responses on a measure of depression standardized on healthy children across a wide age group. As part of the assessment battery, a new self-report scale appropriate for preschool children in hospital settings was designed based on items from the BUMP-R. For the older children, this self-report pediatric-specific measure was compared to the traditionally used CDI. Across informants, the pediatric-specific measures should be intercorrelated, demonstrating convergent validity. Moreover, the depression measures for healthy children should correlate more strongly with each other than with the pediatricspecific measures, evidencing discriminant validity. An additional comparison across context was performed using parent report of behavior in the hospital versus home; the pediatric-specific measures should be correlated more strongly with the hospital ratings than with the home ratings.