Caesarean delivery on maternal request and childhood psychopathology: a retrospective cohort study in China

OBJECTIVE

To prospectively examine the association between mode of delivery and childhood psychopathology.

DESIGN

Retrospective cohort study.

SETTING

Eighteen counties and three cities in China.

POPULATION

A total of 4190 preschool children whose mothers were registered in a perinatal surveillance programme were assessed with the Child Behaviour Checklist (CBCL), an instrument to assess child emotional (internalising) and behavioural (externalising) problems.

METHODS

Differences in CBCL problem scores were analysed both quantitatively and categorically among children born by caesarean delivery on maternal request (CDMR), assisted vaginal delivery (AVD), and spontaneous vaginal delivery (SVD).

MAIN OUTCOME MEASURES

The CBCL total, externalising, and internalising scores.

RESULTS

There were significant differences in the mean scores of total (20.9, 23.0, and 25.0), externalising (7.6, 8.4, and 9.1), and internalising (4.7, 5.2, and 5.6) problems among children born by CDMR, SVD, and AVD, after adjusting for potential confounding factors (P = 0.007, 0.014, and 0.031). Children born by AVD were more likely than those born by SVD to have total (OR 1.43; 95% CI 1.10-1.86), externalising (OR 1.46; 95% CI 1.11-1.92), and internalising (OR 1.41; 95% CI 1.08-1.84) scores in the highest quartile, whereas children born by CDMR were less likely to have externalising scores in the highest quartile (OR 0.64; 95% CI 0.42-0.97). Furthermore, there were significant increasing linear trends on all problem scores, and in the odds of being in the highest quartile, from children born by CDMR to those born by SVD and AVD.

CONCLUSION

The likelihood of childhood psychopathological problems may be the lowest in children born by CDMR, followed by those born by SVD, whereas the highest probability was observed in those born by AVD.

Multicultural evidence-based assessment of child and adolescent psychopathology

This article presents multicultural ways to advance knowledge of children's problems, to fashion conceptual and practical mental health tools, and to use these tools to help children. Diagnostically based scales and statistically derived syndromes are scored from parallel forms completed by population samples of parents, caregivers, teachers, and youths in many societies. The scores are incorporated into multicultural norms for evaluating individual children, as rated by different respondents in relation to relevant norms, such as norms for host societies where immigrant children reside and norms for their families' home societies. Syndrome structures have been supported in 44 societies. Certain age, gender, and SES effects are consistent across many societies. As reported in over 7000 publications from 85 societies and cultural groups, evidence-based assessment provides a common data language for clinicians, trainees, and researchers around the world.

Broad spectrum assessment of psychopathology and adaptive functioning with the Older Adult Behavior Checklist: a validation and diagnostic discrimination study

OBJECTIVE

Self-administered by spouses and other collateral informants, the nationally normed Older Adult Behavior Checklist (OABCL) provides standardized data on diverse aspects of older adult psychopathology and adaptive functioning. We tested the validity of the Older Adult Behavior Checklist (OABCL) scale scores in terms of associations with diagnoses of dementia of the Alzheimer's type (DAT) and mood disorders (MD) and with nine measures of psychopathology, cognitive performance, and adaptive functioning.

METHOD

Informants completed OABCLs for 727 60-97-year-olds recruited from a memory disorders clinic, geriatric psychiatry clinic, and community-dwelling seniors. OABCL scale scores were tested for associations with DAT and MD diagnoses, as well as with scores on the Neuropsychiatric Inventory, Mini-Mental State Exam (MMSE), Clock Drawing Test, Alzheimer's Disease Assessment Scale, Geriatric Depression Scale, Clinical Dementia Rating, Dementia Severity Rating Scale, Trail Making Test Part A, and Instrumental Activities of Daily Living.

RESULTS

OABCL scales had medium to large correlations with the nine other indices of functioning and significantly augmented MMSE discrimination between patients with DAT versus MD. OABCL scales also discriminated significantly between patients diagnosed with DAT versus MD and both these groups versus nonclinical subjects.

CONCLUSIONS

Multiple OABCL scales had medium to large associations with diverse indices of functioning based on other kinds of data. The nationally normed OABCL provides new ways to integrate informant and self-report data to improve assessment of older adults. Specifically, the OABCL can provide discrimination between those who qualify for diagnoses of DAT versus MD versus neither diagnosis.

Differential symptom expression and somatization in Thai versus U.S. children

Individuals react in a variety of ways when experiencing environmental challenges exceeding their capacity to cope adaptively. Some researchers have suggested that Asian populations tend to react to excessive stress with somatic symptoms, whereas Western populations tend to respond more with affective or depressive symptoms. Other researchers, however, have suggested that such differences may represent different approaches to help seeking rather than actual variations in prevalence. The present study compared somatic versus affective symptoms in U.S. and Thai children from community and mental health clinic samples. In the clinic-referred sample, Thai children were reported to have higher levels of somatic versus depressive symptoms relative to U.S. children, whereas in the community sample, both groups were reported to have slightly higher levels of depressive than somatic symptoms. Because a primary difference between clinic-referred and community samples is that the former have been through the clinical referral process (i.e., were seeking help), these results suggest that differences in somatic versus depressive symptom presentation may be related to help-seeking behavior, at least for the samples involved in this study.

Seasonal trends in depressive problems among United States children and adolescents: a representative population survey

This study examined season-of-assessment differences in parent and child reports of depressive problems on well-validated instruments in 2009 U.S. children and adolescents, aged 6 to 18 years, from a nationally representative population survey. A parent completed the Child Behavior Checklist (CBCL) for each participant and 1226 of the 11-18-year-olds completed the Youth Self-Report (YSR). Outcome measures were CBCL and YSR withdrawn/depressed syndrome scale scores and rates of clinically elevated scores. Overall fall/winter versus spring/summer differences were not found on the CBCL or YSR for depressive problem severity or rates of depressive problems. Age, sex, and latitude were examined as potential moderators of the association between season-of-assessment and the outcomes. Of these, the effect of season-of-assessment on CBCL depressive problem severity depended upon age. Parents of 16-18-year-old adolescents rated depressive problems as significantly more severe in fall and winter than in spring and summer. Parents also rated depressive problems as significantly more severe in 16-18-year-olds than in 6-15-year-olds, but only when assessed in the fall and winter. There were no season-of-assessment differences among 6-15-year-old children and adolescents. The overall lack of season-of-assessment differences and the finding of age as a moderator on only one of four outcomes suggest minimal seasonality effects.

Meta-analyses of agreement between diagnoses made from clinical evaluations and standardized diagnostic interviews

Standardized diagnostic interviews (SDIs) have become de facto gold standards for clinical research. However, because clinical practitioners seldom use SDIs, it is essential to determine how well SDIs agree with clinical diagnoses. In meta-analyses of 38 articles published from 1995 to 2006 (N = 15,967 probands), mean kappas (z-transformed) between diagnoses from clinical evaluations versus SDIs were 0.27 for a broad category of all disorders, 0.29 for externalizing disorders, and 0.28 for internalizing disorders. Kappas for specific disorders ranged from 0.19 for generalized anxiety disorder to 0.86 for anorexia nervosa (median = 0.48). For diagnostic clusters (e.g. psychotic disorders), kappas ranged from 0.14 for affective disorders (including bipolar) to 0.70 for eating disorders (median = 0.43). Kappas were significantly higher for outpatients than inpatients and for children than adults. However, these effects were not significant in meta-regressions.

CONCLUSIONS

Diagnostic agreement between SDIs and clinical evaluations varied widely by disorder and was low to moderate for most disorders. Thus, findings from SDIs may not fully apply to diagnoses based on clinical evaluations of the sort used in the published studies. Rather than implying that SDIs or clinical evaluations are inferior, characteristics of both may limit agreement and generalizability from SDI findings to clinical practice.

Behavioral and emotional problems of Algerian children and adolescents as reported by parents

OBJECTIVE

To determine the level of behavioral and emotional problems among a sample of Algerian children and adolescents aged 6-18 years living in Algiers.

METHOD

A school-based sample of 1,405 children and adolescents was recruited; problems were assessed with the Child Behavior Checklist filled out by parents or surrogates.

RESULTS

The scores varied with age, gender, and socioeconomic status (SES). Contrary to findings in other samples, most Problem scores increased with age. As found in many other cultures, girls scored higher than boys on the Internalizing scales, but lower on Externalizing scales. Youths from lower socioeconomic families tended to score higher on some Problem scales. But, above all, Algerian children and adolescents had raw scores on all Problem scales much higher than those yielded by most previous cross-cultural studies.

CONCLUSIONS

The high level of problems may be attributable to traumatic environmental factors (terrorism and natural catastrophes), but the lack of data from countries that have similar geographic and cultural environments makes it hard to exclude explanations based on cultural factors.

Effects of estimation methods on making trait-level inferences from ordered categorical items for assessing psychopathology

In assessments of attitudes, personality, and psychopathology, unidimensional scale scores are commonly obtained from Likert scale items to make inferences about individuals' trait levels. This study approached the issue of how best to combine Likert scale items to estimate test scores from the practitioner's perspective: Does it really matter which method is used to estimate a trait? Analyses of 3 data sets indicated that commonly used methods could be classified into 2 groups: methods that explicitly take account of the ordered categorical item distributions (i.e., partial credit and graded response models of item response theory, factor analysis using an asymptotically distribution-free estimator) and methods that do not distinguish Likert-type items from continuously distributed items (i.e., total score, principal component analysis, maximum-likelihood factor analysis). Differences in trait estimates were found to be trivial within each group. Yet the results suggested that inferences about individuals' trait levels differ considerably between the 2 groups. One should therefore choose a method that explicitly takes account of item distributions in estimating unidimensional traits from ordered categorical response formats. Consequences of violating distributional assumptions were discussed.

Multicultural assessment of child and adolescent psychopathology with ASEBA and SDQ instruments: research findings, applications, and future directions

Around the world, cultural blending and conflict pose challenges for assessment and understanding of psychopathology. Economical, evidence-based, culturally robust assessment is needed for research, for answering public health questions, and for evaluating immigrant, refugee, and minority children. This article applies multicultural perspectives to behavioral, emotional, and social problems assessed on dimensions describing children's functioning, as rated by parents, teachers, children, and others. The development of Achenbach System of Empirically Based Assessment (ASEBA) and Strengths and Difficulties Questionnaire (SDQ) forms and their applications to multicultural research are presented. A primary aim of both questionnaires is to identify children at high risk of psychiatric disorders and who therefore warrant further assessment. The forms are self-administered or administered by lay interviewers. ASEBA problem items are scored on 6 DSM-oriented scales and 3 broader band scales, plus 8 syndromes derived statistically as taxonomic constructs and supported by uniform confirmatory factor analyses of samples from many populations. Comparisons of ASEBA scale scores, psychometrics, and correlates are available for diverse populations. SDQ forms are scored on one broad-band scale and 5 a priori behavioral dimensions supported by data from various populations. For both instruments, factor analyses, psychometrics, and correlates are available for diverse populations. The willingness and ability of hundreds of thousands of respondents from diverse groups to complete ASEBA and SDQ forms support this approach to multicultural assessment. Although particular items and scales may have differential relevance among groups and additional assessment procedures are needed, comparable results are found in many populations. Scale scores vary more within than between populations, and distributions of scores overlap greatly among different populations. Ratings of children's problems thus indicate more heterogeneity within populations than distinctiveness between populations. Norms from multiple populations can be used to compare children's scores with relevant peer groups. Multicultural dimensional research can advance knowledge by diversifying normative data; by comparing immigrant children with nonimmigrant compatriots and with host country children; by identifying outlier findings for elucidation by emic research; and by fostering efforts to dimensionalize DSM-V diagnostic criteria.

The generalizability of the Youth Self-Report syndrome structure in 23 societies

As a basis for theories of psychopathology, clinical psychology and related disciplines need sound taxonomies that are generalizable across diverse populations. To test the generalizability of a statistically derived 8-syndrome taxonomic model for youth psychopathology, confirmatory factor analyses (CFAs) were performed on the Youth Self-Report (T. M. Achenbach & L. A. Rescorla, 2001) completed by 30,243 youths 11-18 years old from 23 societies. The 8-syndrome taxonomic model met criteria for good fit to the data from each society. This was consistent with findings for the parent-completed Child Behavior Checklist (Achenbach & Rescorla, 2001) and the teacher-completed Teacher's Report Form (Achenbach & Rescorla, 2001) from many societies. Separate CFAs by gender and age group supported the 8-syndrome model for boys and girls and for younger and older youths within individual societies. The findings provide initial support for the taxonomic generalizability of the 8-syndrome model across very diverse societies, both genders, and 2 age groups.

Testing the 8-syndrome structure of the child behavior checklist in 30 societies

There is a growing need for multicultural collaboration in child mental health services, training, and research. To facilitate such collaboration, this study tested the 8-syndrome structure of the Child Behavior Checklist (CBCL) in 30 societies. Parents' CBCL ratings of 58,051 6- to 18-year-olds were subjected to confirmatory factor analyses, which were conducted separately for each society. Societies represented Asia; Africa; Australia; the Caribbean; Eastern, Western, Southern, and Northern Europe; the Middle East; and North America. Fit indices strongly supported the correlated 8-syndrome structure in each of 30 societies. The results support use of the syndromes in diverse societies.

Epidemiological comparisons of problems and positive qualities reported by adolescents in 24 countries

In this study, the authors compared ratings of behavioral and emotional problems and positive qualities on the Youth Self-Report (T. M. Achenbach & L. A. Rescorla, 2001) by adolescents in general population samples from 24 countries (N = 27,206). For problem scales, country effect sizes (ESs) ranged from 3% to 9%, whereas those for gender and age ranged from less than 1% to 2%. Scores were significantly higher for girls than for boys on Internalizing Problems and significantly higher for boys than for girls on Externalizing Problems. Bicountry correlations for mean problem item scores averaged .69. For Total Problems, 17 of 24 countries scored within one standard deviation of the overall mean of 35.3. In the 19 countries for which parent ratings were also available, the mean of 20.5 for parent ratings was far lower than the self-report mean of 34.0 in the same 19 countries (d = 2.5). Results indicate considerable consistency across 24 countries in adolescents' self-reported problems but less consistency for positive qualities.

A dimensional approach to developmental psychopathology

The expression psychopathology in general and child psychopathology in particular, is affected by multiple sources of variance. Some of these sources include gender differences, informant differences, and age-related differences. In this paper, we discuss how these sources of variance complicate both research and clinical management. We argue that the current diagnostic system would be aided by the inclusion of a quantitative axis that can take these sources of variance into account. We reason that the fields of genomics and neuroscience are prepared to move the field of developmental psychopathology forward, but need a diagnostic system that allows for these sources of variance to be controlled. We demonstrate how in Conduct Disorder, inclusion of dimensional information would allow the clinician or researcher to demonstrate not only the presence or absence of pathology, but also the degree to which the disorder is manifested in a particular individual. Because dimensional approaches are already used widely as an alternative measure of psychopathology, we argue that there is reason to consider dimensionalizing some aspects of the DSM.

Advancing assessment of children and adolescents: commentary on evidence-based assessment of child and adolescent disorders

This article addresses the following cross-cutting issues evident in the special section of this issue: (a) current diagnoses do not provide adequate validity criteria; (b) the heterogeneity and comorbidity of target problems raise taxonomic challenges; (c) accurate assessment requires integration of multisource data; (d) developmental variations must be accommodated; (e) appropriate norms are needed; and (f) categorical and quantitative approaches are not incompatible. Less evident in the special section articles but equally important are the need to cope with multicultural issues, avoid premature closure regarding diagnostic labels, assess caregivers, and standardize broad-spectrum assessment procedures. Studies and use of evidence-based treatment (EBT) should be linked to evidence-based assessment (EBA) to advance both EBT and EBA.

DSM-oriented scales and statistically based syndromes for ages 18 to 59: linking taxonomic paradigms to facilitate multitaxonomic approaches

We used behavioral and emotional problem items to construct (a) nosologically based Diagnostic and Statistical Manual of Mental Disorders (DSM) oriented scales from experts' ratings of the items' consistency with DSM-IV (4th ed.; American Psychiatric Association, 1994) diagnostic categories, and (b) statistically based syndromes from factor analyses of adults' self-ratings and ratings of adults by people who knew them (N = 4,628). Quantified, operationally defined, and normed DSM-oriented scales and statistically based syndromes facilitate multitaxonomic approaches to the assessment of adult psychopathology. Psychometric properties and cross-informant correlations were similar for DSM-oriented scales and statistically derived syndromes. Statistical associations between phenotypically similar DSM-oriented scales and statistically based syndromes were moderate to strong. Multitaxonomic approaches can avoid reification of provisional taxa that may result from excessive reliance on a single taxonomic paradigm.

Assessment of Adult Psychopathology: Meta-Analyses and Implications of Cross-Informant Correlations

Assessment of adult psychopathology relies heavily on self-reports. To determine how well self-reports agree with reports by "informants" who know the person being assessed, the authors examined 51,000 articles published over 10 years in 52 peer-reviewed journals for correlations between self-reports and "informants" reports. Qualifying correlations were found in 108 (0.2%) of the articles. When self-reports and informant reports were obtained with parallel instruments, mean cross-informant correlations were .681 for substance use, .428 for internalizing, and .438 for externalizing problems. When based on different instruments, the mean cross-informant correlation was .304. The moderate sizes of the correlations argue for systematically obtaining multi-informant data. National survey findings were used to illustrate practical ways to obtain and use such data.

Explaining the Link Between Low Socioeconomic Status and Psychopathology: Testing Two Mechanisms of the Social Causation Hypothesis

Two mechanisms of the hypothesized social causation of psychopathology--differential incidence and cumulative prevalence--were tested over 9 years in a nationally representative sample of 1,075 children and youths, ages 8-17 at Time 1 (1986). Analyses using parental responses on behavior checklists at 4 time points showed significant increases in clinical elevations for those of the lowest socioeconomic status (SES) on anxious/depressed, somatic complaints, thought problems, delinquent, and aggressive syndromes. This SES-linked differential incidence supports the social causation hypothesis that factors associated with SES contribute to variations in levels of psychological problems. SES-linked differential cumulative prevalence was found for withdrawn and somatic complaints; this finding indicates that low-SES cases do not improve as much as do middle- and high-SES cases, which results in greater accumulation of low-SES cases.

Measurement Structure of the Turkish Translation of the Child Behavior Checklist Using Confirmatory Factor Analytic Approaches to Validation of Syndromal Constructs

The new correlated 8-factor measurement structure of the Child Behavior Checklist for ages 6-18 (CBCL/6-18; T. M. Achenbach & L. A. Rescorla, 2001) derived from an American sample was used as a benchmark to evaluate its generalizability to Turkish general population (N = 5,195) and clinical (N = 963) samples. Item-level confirmatory factor analysis (CFA) was used to evaluate the adequacy of the correlated 8-factor model across 3 sample conditions (general population, clinical, and combined sample whose Total Problems scores were above the Turkish national median). The results supported the generalizability of the overall measurement structure of the CBCL to the Turkish population.

DSM-oriented and empirically based approaches to constructing scales from the same item pools

Separately for ages 11/2 to 5 and 6 to 18, used items for rating behavioral and emotional problems to construct (a). "top-down" DSM-oriented scales from experts' ratings of the items' consistency with Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV], American Psychiatric Association, 1994) categories, and (b). "bottom-up" empirically based syndromes from factor analyses of parent, caregiver, teacher, and self ratings (N = 14853). Both kinds of scales are scored from the same assessment instruments and are displayed on profiles normed on the same national samples. Psychometric properties were similar for both kinds of scales. Associations between counterpart scales were medium to strong. Quantified, normed DSM-oriented and empirically based scales scored from the same instruments can facilitate assessment of individuals, statistical analyses for research purposes, and integration of top-down and bottom-up approaches to deriving constructs for psychopathology.

Comparisons of problems reported by youths from seven countries

OBJECTIVE

This study compared ratings for self-reported behavioral and emotional problems in adolescents from seven countries.

METHOD

Youth Self-Report scores were analyzed for 7,137 adolescents ages 11-18 years from general population samples from Australia, China, Israel, Jamaica, the Netherlands, Turkey, and the United States.

RESULTS

Comparisons of problems scores yielded small to medium effect sizes for cross-cultural variations. Youths from China and Jamaica had the highest and youths from Israel and Turkey had the lowest mean total problems scores. With cross-cultural consistency, girls scored higher for internalizing and lower for externalizing than boys. Cross-cultural correlations were high among the mean item scores.

CONCLUSIONS

Empirically based assessment provided a robust method for assessing and comparing adolescents' self-reported problems. Self-reports thus supplemented empirically based assessments of parent-reported problems and offered a cost-effective way of identifying problems for which adolescents from diverse cultural backgrounds may need help.

Genetic influences on childhood competencies: a twin study

OBJECTIVE

To estimate genetic, environmental, and rater contrast influences on parental reports of Activities, Social, School, and Total Competence scales of the Child Behavior Checklist (CBCL).

METHOD

Parents of 492 twin pairs aged 8-12 years completed CBCLs. Genetic, shared and unique environmental, and rater bias effects were estimated for the Activities, Social, School, and Total Competence scales. Data on boys and girls were analyzed separately.

RESULTS

Moderate genetic influences were found only for the School scale (60%-76%), while shared environment accounted for most of the variance in Activities, Social, and Total Competence scales. Gender differences are reported. Similar to a prior twin study of CBCL problem syndromes, there was no evidence of rater bias.

CONCLUSIONS

Estimates of genetic influence on these child competence domains were high for School Competence, while social competence and activity competence evidenced higher levels of shared environmental influences. Organization and wording of CBCL items may avoid rater biases in reporting. These findings have implications for interventions to improve school, social, and activities competence.

Are American children's problems still getting worse? A 23-year comparison

Child Behavior Checklists were completed in home interviews by parents of 7-16-year-olds in 1976, 1989, and 1999. Competence scores decreased from 1976 to 1989, but increased in 1999. Problem scores increased from 1976 to 1989 and decreased in 1999 but remained higher than in 1976. Items, empirically based scales, and DSM-oriented scales showed similar patterns for demographically similar nonreferred samples assessed in 1976, 1989, and 1999 and for national samples that included referred children assessed in 1989 and 1999. For the 114 problem items that were common to the 1976, 1989, and 1999 assessments, the Q correlation was .98 between the mean scores on the 114 items in 1976 versus 1989 and was .94 between the mean scores on the 114 items in 1976 vs. 1999. This indicated very high stability in the rank ordering of item scores across intervals up to 23 years. For all children, the 1-year prevalence rate for mental health services use was 13.2% in 1989 versus 12.8% in 1999. For children with deviant Total Problems scores, the 1989 prevalence for service use was 30.5 versus 26.6% in 1999. Neither difference was statistically significant.

Use of the language development survey (LDS) in a national probability sample of children 18 to 35 months old

Data are reported from a national probability sample used to norm the Language Development Survey (LDS; L. Rescorla, 1989) and the Child Behavior Checklist for Ages 1 1/2-5 (CBCL/1 1/25; T. M. Achenbach & L. Rescorla, 2000). Participants were 278 children 18 to 35 months old who were highly diverse in socioeconomic status (SES), ethnic composition, and language background. Vocabulary scores increased markedly with age, were somewhat higher in girls, and were modestly correlated with SES. Children of non-Latino White ethnicity had significantly higher vocabulary scores and mean length of phrases than children of African American or "other" ethnicity (Hispanics/Asians/Native Americans/South Asians/mixed), even when SES was used as a covariate. Rate of language delay, using the cut-off of fewer than 50 words or no word combinations, was lower in the non-Latino White group (4%) than in the other two ethnicity groups (29% and 24%). Correlations between LDS scores and problem scores on the CBCL/1 1/2-5 were low, indicating that language delay and emotional/behavior problems were not closely associated in this general population sample of children 18 to 35 months old.

Advances in empirically based assessment: revised cross-informant syndromes and new DSM-oriented scales for the CBCL, YSR, and TRF: comment on Lengua, Sadowksi, Friedrich, and Fischer (2001)

L. Lengua et al. (2001) proposed scoring the Child Behavior Checklist (CBCL; T. Achenbach, 1991b) on dimensions that "correspond to current conceptualizations of child symptomatology," (p. 695) embodied in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; 4th ed., American Psychiatric Association, 1994). They concluded that their "results support the use of the new dimensions." Yet, their regressions and diagnostic efficiency statistics showed that DSM diagnoses were predicted less well by their dimensions than by CBCL syndromes that reflect actual patterns of problems. Not only these findings, but also the high correlations of their dimensions with CBCL syndromes and the lack of norms and validated clinical cutoffs for their dimensions, argue against use of their dimensions. To advance assessment and taxonomy, new national samples have been used to construct DSM-oriented scales and to revise cross-informant syndromes.

Challenges and benefits of assessment, diagnosis, and taxonomy for clinical practice and research

OBJECTIVE

To outline nosological (top-down) and empirically based (bottom-up) approaches to assessment and taxonomy of psychopathology.

METHOD

The two approaches were compared and contrasted to highlight similarities and differences between them.

RESULTS AND CONCLUSIONS

To advance services and research, we need to make optimal use of assessment data (i) to identify the distinguishing features of each case, and (ii) to link individual patterns of functioning with taxonomic constructs that can help us apply previously accumulated knowledge to new cases. The time may be ripe for integrating nosological and empirically based approaches. One way to integrate these approaches is to construct empirically based and DSM-oriented scales from the same item pools and to generate age- and gender-specific standard scores and cut-off points from the same normative samples. Integration of the approaches was illustrated with profiles of empirically based and DSM-oriented scales scored from the same item pools and quantified in relation to the same normative samples. To facilitate use by clinicians and researchers under diverse conditions, data are readily obtained on forms completed independently by parents, teachers and others. The data can be quickly scored by hand or computer. To take account of situational and informant variations, the computer software systematically compares data from multiple informants on empirically based and DSM-oriented scales.

Latent class analysis of child behavior checklist anxiety/depression in children and adolescents

OBJECTIVE

Comorbidity of psychiatric problems such as anxiety and depression poses challenges to treatment and research. This study tested whether problem items from the Anxious/Depressed scale of the Child Behavior Checklist (CBCL) can be separated into distinct anxiety and depression classes or are continuously distributed throughout a population.

METHOD

A CBCL was completed by a parent or guardian of each of 1,987 children and adolescents selected to represent nonreferred children in the United States, as well as by a parent or guardian of each of a demographically matched sample of 1,987 clinically referred children and adolescents. Problem items from the Anxious/Depressed scale of the CBCL were subjected to latent class analysis.

RESULTS

Analyses revealed three levels of problem presentation in both samples. Children in the nonreferred sample were classified as having no problems, mild problems, or moderate anxiety/depression problems. Children and adolescents in the referred group were classified as having mild, moderate, or severe levels of problems. No pure anxiety or depression classes were found, only classes containing a mixture of both anxiety and depressive problems. Age, gender, and sample differences were found in class groupings, with nonreferred adolescent girls showing elevated levels of problems.

CONCLUSIONS

Results suggest that the comorbid conditions of anxiety and depression, as assessed by the CBCL anxiety/depression problem items, can be thought of as part of the same continuum of problems. Implications for assessment and treatment utilization are discussed.

Attention problems versus conduct problems as 6-year predictors of signs of disturbance in a national sample

OBJECTIVE

To test whether attention problems predicted different signs of disturbance than conduct problems over 3 and 6 years.

METHOD

Gender-specific criteria for deviance on parents' ratings of attention versus conduct problems were tested as predictors of interview-reported signs of disturbance in a national sample first assessed at ages 4 to 16 years.

RESULTS

Males and females deviant on both attention and conduct problems showed higher rates of several signs of disturbance than did those deviant on only one type of problem. Subjects deviant only on conduct problems showed higher rates of several signs than did controls, whereas those deviant only on attention problems exceeded controls mainly on special education services. Unaggressive "delinquent" conduct problems predicted dropping out of school, unwed pregnancy, and total signs for both genders during transitions to adulthood.

CONCLUSIONS

Attention problems predict receipt of special education but contribute much less than conduct problems to predicting other signs of disturbance. Differential assessment of aggressive versus unaggressive conduct problems can improve prediction, as can gender specificity in setting criteria for deviance and in testing outcomes.

Latent class analysis of Child Behavior Checklist attention problems

OBJECTIVE

To test whether attention problems in children are continuously distributed or categorically discrete, the authors performed latent class analyses (LCA) of items from the Attention Problems scale of the Child Behavior Checklist (CBCL) using data from the clinical and nonclinical samples used in the derivation of the CBCL syndromes.

METHOD

A CBCL was completed by a parent or guardian of each of 2,100 nonreferred children selected to be representative of U.S. nonreferred children and a demographically matched sample of 2,100 clinically referred children. Attention problems symptoms were subjected to LCA.

RESULTS

LCAs were consistent with the presence of 3 levels of symptom presentation in both samples. Children in the nonclinical sample were classified as having no symptoms, mild symptoms, or moderate symptoms. Children in the clinical group had mild, moderate, or severe symptoms.

CONCLUSIONS

These results suggest that child and adolescent psychiatric symptoms such as attention problems can be thought of as continuously distributed phenomena rather than discrete disease entities, lending support for an empirical approach to both clinical work and research. In addition, high prevalence rates of attention problems in both clinical and nonclinical samples suggest the need for careful screening of attention problems in clinic and academic settings.

Problems reported by parents of children in multiple cultures: the Child Behavior Checklist syndrome constructs

OBJECTIVE

The purpose of this study was to compare syndromes of parent-reported problems for children in 12 cultures.

METHOD

Child Behavior Checklists were analyzed for 13,697 children and adolescents, ages 6 through 17 years, from general population samples in Australia, Belgium, China, Germany, Greece, Israel, Jamaica, the Netherlands, Puerto Rico, Sweden, Thailand, and the United States.

RESULTS

Comparisons of nine cultures for subjects ages 6 through 17 gave medium effect sizes for cross-cultural variations in withdrawn and social problems and small effect sizes for somatic complaints, anxious/depressed, thought problems, attention problems, delinquent behavior, and aggressive behavior. Scores of Puerto Rican subjects were the highest, whereas Swedish subjects had the lowest scores on almost all syndromes. With great cross-cultural consistency, girls obtained higher scores than boys on somatic complaints and anxious/depressed but lower scores on attention problems, delinquent behavior, and aggressive behavior. Although remarkably consistent across cultures, the developmental trends differed according to syndrome. Comparison of the 12 cultures across ages 6 through 11 supported these results.

CONCLUSIONS

Empirically based assessment in terms of Child Behavior Checklist syndromes permits comparisons of problems reported for children from diverse cultures.

Six-year predictors of problems in a national sample: IV. Young adult signs of disturbance

OBJECTIVE

To identify adolescent predictors of young adult signs of disturbance.

METHOD

Family variables and parent- and self-reported syndromes, competencies, and stressful experiences were tested as predictors of school dropout, unwed pregnancy, substance use, mental health services, suicidal behavior, police contacts, and being fired from jobs.

RESULTS

Most signs were predictable with considerable accuracy, especially suicidal behavior and being fired from jobs among females. The Delinquent Behavior syndrome and poor school functioning predicted the most poor outcomes. Concurrent scores on young adult syndromes were significantly associated with most signs.

CONCLUSIONS

Across the diversity of a national sample, young adult signs of disturbance were predictable from risk and protective factors assessed in adolescence. The predictors can help to identify youth at risk for particular signs. Parents are important contributors to assessment of young adults' problems.

Gender differences in depressive symptoms in adolescence: comparison of national samples of clinically referred and nonreferred youths

Gender differences in depressed mood, a syndrome of mixed anxiety-depression, and an analogue of major depressive disorder were compared in parents' and adolescents' reports in 2 large, demographically matched national samples of clinically referred and nonreferred adolescents. Referral status accounted for the greatest share of the variance in these problems. Gender differences were moderate in size and consistent in referred youths, with referred girls scoring higher than referred boys on all measures, whereas gender differences in nonreferred adolescents were either nonsignificant or small in magnitude. Gender differences were also larger in magnitude in adolescents' self-reports than in parents' reports. The interaction of age and gender was nonsignificant in all analyses. Implications for understanding the extent of gender differences in adolescents' depressive symptoms are highlighted.

Comparisons of problems reported by parents of children in 12 cultures: total problems, externalizing, and internalizing

OBJECTIVE

To compare parent-reported problems for children in 12 cultures.

METHOD

Child Behavior Checklists were analyzed for 13,697 children and adolescents, aged 6 through 17 years, from general population samples in Australia, Belgium, China, Germany, Greece, Israel, Jamaica, the Netherlands, Puerto Rico, Sweden, Thailand, and the United States.

RESULTS

Comparisons of 12 cultures across ages 6 through 11 and 9 cultures across ages 6 through 17 yielded medium effect sizes for cross-cultural variations in Total Problem, Externalizing, and Internalizing scores. Puerto Rican scores were the highest, while Swedish scores were the lowest. With great cross-cultural consistency, Total and Externalizing scores declined with age, while Internalizing scores increased; boys obtained higher Total and Externalizing scores but lower Internalizing scores than girls. Cross-cultural correlations were high among the mean item scores.

CONCLUSIONS

Empirically based assessment provides a robust methodology for assessing and comparing problems reported for children from diverse cultures. Age and gender variations are cross-culturally consistent. Although clinical cutoff points should not necessarily be uniform across all cultures, empirically based assessment offers a cost-effective way to identify problems for which children from diverse cultural backgrounds may need help.

Gender differences in depressive symptoms in adolescence: comparison of national samples of clinically referred and nonreferred youths

Gender differences in depressed mood, a syndrome of mixed anxiety-depression, and an analogue of major depressive disorder were compared in parents' and adolescents' reports in 2 large, demographically matched national samples of clinically referred and nonreferred adolescents. Referral status accounted for the greatest share of the variance in these problems. Gender differences were moderate in size and consistent in referred youths, with referred girls scoring higher than referred boys on all measures, whereas gender differences in nonreferred adolescents were either nonsignificant or small in magnitude. Gender differences were also larger in magnitude in adolescents' self-reports than in parents' reports. The interaction of age and gender was nonsignificant in all analyses. Implications for understanding the extent of gender differences in adolescents' depressive symptoms are highlighted.

Covariation of the anxious-depressed syndrome during adolescence: separating fact from artifact

Nosological (symptom overlap) and methodological (informant) artifact in the covariation of an empirically derived syndrome of anxious-depressed symptoms with 7 other syndromes of emotional and behavior problems was examined in reports by parents, teachers, and adolescents on a nationally representative sample of 908 adolescents. Although minor symptom overlap was observed and the effects of informant were significant, the anxious-depressed syndrome covaried significantly with all other syndromes after controlling for these effects. Indices of covariation controlling for informant effects were all significant and ranged for all syndromes except for delinquent behavior from .619 to .681, reflecting significant covariation of the anxious-depressed syndrome with both externalizing and internalizing syndromes. Covariation of the anxious-depressed syndrome and delinquent behavior was .470. Implications for research on the comorbidity-covariation of depressive syndromes during childhood and adolescence are highlighted.

Covariation of the anxious-depressed syndrome during adolescence: separating fact from artifact

Nosological (symptom overlap) and methodological (informant) artifact in the covariation of an empirically derived syndrome of anxious-depressed symptoms with 7 other syndromes of emotional and behavior problems was examined in reports by parents, teachers, and adolescents on a nationally representative sample of 908 adolescents. Although minor symptom overlap was observed and the effects of informant were significant, the anxious-depressed syndrome covaried significantly with all other syndromes after controlling for these effects. Indices of covariation controlling for informant effects were all significant and ranged for all syndromes except for delinquent behavior from .619 to .681, reflecting significant covariation of the anxious-depressed syndrome with both externalizing and internalizing syndromes. Covariation of the anxious-depressed syndrome and delinquent behavior was .470. Implications for research on the comorbidity-covariation of depressive syndromes during childhood and adolescence are highlighted.

Accelerated longitudinal comparisons of aggressive versus delinquent syndromes

Accelerated longitudinal analyses revealed both similarities and differences between the developmental trajectories of empirically based aggressive versus delinquent syndromes in childhood and adolescence. Syndromes were scored from standardized ratings obtained from parents five times at 2-year intervals for seven birth cohorts of Dutch children initially assessed at ages 4 to 10 years. Scores for both the aggressive and delinquent syndromes declined from ages 4 to 10. After about age 10 years, scores for the aggressive syndrome continued to decline, but scores for the delinquent syndrome increased until about age 17. The aggressive syndrome was significantly more stable than the delinquent syndrome. Long-term predictive correlations between matched subjects from different cohorts were as high as predictive correlations between scores obtained by the same subjects, thus supporting the validity of accelerated longitudinal analyses. The results highlight important developmental distinctions between aggressive versus delinquent conduct problems. Failure to distinguish between aggressive and delinquent conduct problems could generate misleading conclusions about their respective developmental courses and limit the generalizability of results.

Predictors of cross-informant syndromes among children and youths referred for mental health services

This study sought to identify which syndromes of initial problems predicted later syndromes among children and youths referred for mental health services. Standardized parent reports on the Child Behavior Checklist obtained at intake were compared to standardized parent, teacher, and self-reports obtained at follow-up. There were 1,103 subjects (774 males and 329 females) 4 to 18 years old, followed up an average of 6 years after referral. High quantitative and categorical stability was found for cross-informant syndromes within samples of younger and older subjects. Throughout childhood and into young adulthood, parent ratings of most syndromes at the time of referral predicted the counterpart cross-informant syndrome construct at follow-up, controlling for other types of problems at referral. There were multiple additional independent predictors of many syndromes, including Delinquent Behavior, Aggressive Behavior, and Shows Off for young adult males. Time 1 Social Problems and Attention Problems independently predicted diverse problems at Time 2 for younger males. A wide variety of problems also predicted younger males' self-ratings of withdrawal, anxiety, and depression. The stability of problems for the referred sample was similar to that found for demographically matched nonreferred subjects drawn from a national sample.

Attention problems versus conduct problems as six-year predictors of problem scores in a national sample

OBJECTIVE

To test the extent to which attention problems, the continuation of early comorbid conduct problems, and overall initial problems account for poor outcome scores on the Child Behavior Checklist and related measures 3 and 6 years after initial assessment.

METHOD

The course of attention and conduct problems was investigated in a nationally representative US sample assessed three times over 6 years, using standardized ratings of attention, conduct, and other problems and gender-specific scores for defining deviance.

RESULTS

Subjects deviant on both attention and conduct problems scored significantly higher on behavior problems at outcome than did those deviant on only attention problems or conduct problems. After controlling for initial conduct problems, initial attention problems made little unique contribution to later conduct problems. Predictive patterns were similar across gender and age groups.

CONCLUSIONS

Both boys and girls who show a combination of attention and conduct problems are at particular risk for the persistence of conduct problems.

Behavioral and emotional problems among Chinese and American children: parent and teacher reports for ages 6 to 13

This study compared behavioral and emotional problems reported by parents and teachers in Chinese urban and rural samples and demographically similar American samples. Parents of 469 6-to-13-year-old children of each nationality completed the Child Behavior Checklist (CBCL). Teachers completed the Teacher's Report Form (TRF). Cross-cultural differences were generally modest in magnitude. Chinese children scored higher on TRF Delinquent Behavior and Anxious/Depressed syndromes, and on Internalizing. American children scored higher on CBCL Aggressive Behavior and TRF Attention Problems syndromes. Boys exhibited more externalizing behaviors across both cultures. The mean correlation between parent and teacher ratings was .36 in the Chinese sample and .29 in the American sample, a nonsignificant difference. Findings indicate considerable similarity between problems reported for children in very different societies.

Six-year predictors of problems in a national sample: III. Transitions to young adult syndromes

OBJECTIVE

To test developmental paths from adolescent syndromes and other candidate predictors to young adult syndromes.

METHOD

A national sample assessed at ages 13 through 16 and 16 through 19 years was reassessed at 19 through 22 years in terms of six syndromes derived empirically from parent and self-reports, two syndromes derived only from parent reports, and one derived from self-reports.

RESULTS

Several young adult syndromes were similar to adolescent syndromes and were strongly predicted by these syndromes. A new syndrome designated as Shows Off and an adult Aggressive Behavior syndrome were both predicted by the adolescent Aggressive Behavior syndrome. This indicates a developmental transition away from overt aggression among some aggressive youths but not others. A syndrome designated as Irresponsible was predicted by the adolescent Attention Problems syndrome and may be an adult phenotype of attention deficit disorder. Surprisingly, attention problems were associated with more diverse problems among females than males.

CONCLUSIONS

There are strong predictive relations from adolescent to adult syndromes. Sex differences in predictive paths argue against basing assumptions about both sexes on findings for one sex.

Six-year predictors of problems in a national sample of children and youth: II. Signs of disturbance

OBJECTIVE

To identify 1986 and 1989 variables that significantly predicted signs of disturbance assessed in 1992.

METHOD

1986 parent reports and 1989 parent, teacher, and self-reports of syndromes, competencies, family variables, and stressful experiences were tested as predictors of 1992 reports of academic problems, school behavior problems, receipt of mental health services, suicidal behavior, police contacts, substance abuse, and the sum of these six signs.

RESULTS

The predictors accounted for large percentages of variance in most signs and predicted fairly accurately which members of case-control samples would manifest specific signs. Overall predictive accuracy was similar for both sexes, but many predictors differed for boys versus girls. The six signs were weakly associated with each other but were strongly associated with particular syndromes.

CONCLUSIONS

Signs of disturbance were predictable over a 6-year period despite the diversity of a national sample. Previous manifestations of certain signs were modest predictors of the same signs. The Delinquent Behavior and Attention Problems syndromes, plus stressful experiences, predicted the most signs. Sex differences in predictors argue against generalizing findings and inferences from one sex to the other.