Instruments for evaluating pharmacotherapy intervention efficacy in violent and aggressive behavior and conduct disorder in youth

Accepted Manuscript Instruments for evaluating pharmacotherapy intervention efficacy in violent and aggressive behavior and conduct disorder in youth

Jessica L. Hambly, Sohil Khan, Brett McDermott, William Bor, Alison Haywood PII: DOI: Reference:

S1359-1789(16)30159-8 doi: 10.1016/j.avb.2017.04.004 AVB 1106

To appear in:

Aggression and Violent Behavior

Received date: Revised date: Accepted date:

15 October 2016 2 March 2017 13 April 2017

Please cite this article as: Jessica L. Hambly, Sohil Khan, Brett McDermott, William Bor, Alison Haywood , Instruments for evaluating pharmacotherapy intervention efficacy in violent and aggressive behavior and conduct disorder in youth. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Avb(2017), doi: 10.1016/j.avb.2017.04.004

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ACCEPTED MANUSCRIPT Instruments for evaluating pharmacotherapy intervention efficacy in violent and aggressive behavior and conduct disorder in youth

Abbreviated Title: Instruments measuring pharmacotherapy efficacy in violent and aggressive youth

Authors: a

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Jessica L Hamblya, Sohil Khana,b, Brett McDermottc, William Borb,d, Alison Haywooda,b School of Pharmacy, Menzies Health Institute Queensland, Griffith University, Gold Coast,

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QLD, 4222, Australia b

Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia

School of Medicine and Dentistry, James Cook University, Townsville, Australia

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c

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Mater Child and Youth Mental Health Service, Mater Health Service, South Brisbane, QLD,

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Australia

Author emails:

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Ms. Jessica Hambly – [email protected] Dr. Sohil Khan – [email protected]

Prof. Brett McDermott – [email protected]

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Dr. William Bor – [email protected]

Corresponding author:

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Jessica Hambly

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Dr. Alison Haywood – [email protected]

School of Pharmacy Gold Coast Campus

Australia

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Griffith University QLD 4222

Tel: + 61 431985230; Fax: + 61 755528804; Email: [email protected]

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ACCEPTED MANUSCRIPT Abstract There is a need to identify the most appropriate standardized instruments for research evaluating pharmacotherapy for youth with violent and aggressive behaviors. Youth violence and aggression are heterogeneous behaviours which differ depending on age and gender. Instruments used in randomized controlled trials evaluating efficacy of pharmacotherapy in conduct disorder and its comorbidities were reviewed for psychometric, administrative and

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practicality evidence. Evidence was rated on a 3-point scale, adapted from the Scientific

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Advisory Committee’s Instrument Review Criteria.

Of the nine included instruments, the Nisonger Child Behavior Rating Form (NCBRF),

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Conners’ 3rd Edition, and Behavior Problems Inventory (BPI-01) were rated the highest for

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their psychometric properties. The Children’s Aggression Scale (CAS), Abberrant Behavior Checklist (ABC) and Disruptive Behavior Disorder Rating Scale (DBDRS) were rated

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moderate, and the Child Behavior Checklist (CBCL), Modified Overt Aggression Scale (MOAS) and Swanson, Nolan, and Pelham Rating Scale (SNAP-IV) were rated lowest. The NCBRF, BPI-01 and CAS were the only instruments that could be used to measure both

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frequency and severity of aggressive behaviors. The CAS and MOAS featured the most items

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pertaining to violence and aggression.

The broad-band scales, the NCBRF and Conners’ 3rd Edition, rated highest for their

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psychometric properties, however their usefulness in youth violence and aggression research is limited. The heterogeneity of aggressive and violent behaviors, age, gender,

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functional level, situational context and the type of informant should be taken into account when considering an appropriate instrument. All items in the CAS and the MOAS can be used to measure violent and/or aggressive behaviors. Further research into the psychometric properties of the MOAS in violent and aggressive youth is required before its use can be recommended. The CAS was found to be the most psychometrically sound and useful instrument that exclusively measures aggressive behaviors in youth.

Keywords: instruments, outcome measures, aggression, violence, youth, efficacy

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ACCEPTED MANUSCRIPT 1.1

BACKGROUND Youth, those less than 25 years old, comprise approximately 44% of the world’s

population (Sawyer et al., 2000b). Half of all cases of diagnosed psychological disorders usually develop before age 14, emphasising the importance of youth in relation to mental health conditions and disorders (Erskine et al., 2015). Recent reviews of 21st century trends suggest declines in youth violent and aggressive behavior across developed nations (Bor, Dean, Najman,

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& Hayatbakhsh, 2014; Collishaw, 2015). Despite the declining or stabilizing levels of youth violent and aggressive behaviors, the moderate to high levels of the associated problems result

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in considerable costs to the affected individuals, their families, and the community (Bor et al.,

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2014). In the United States physical violence in school-aged children was reported at 24.7% in 2013 (Frieden, Jaffe, Cono, Richards, & Iademarco, 2014). Whereas, in China, a large cross-

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sectional sample of urban adolescents revealed self-reported mean rates of physical aggression being 13.38% and verbal aggression 12.95% in 2012 (Zhang et al., 2012). Further, an Australian

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population study found 8.8% of adolescents, 11 to 17 years reported conduct problems (Lawrence et al., 2015), and in the United Kingdom, 6.6% of adolescents, aged 11 to 16

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received a clinical diagnosis of conduct disorder (CD) (Etchells, Gage, Rutherford, & Munafo,

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2016).

Aggression may take many forms (e.g., physical and verbal) and have many functions

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(e.g., impulsive and instrumental) (Farmer et al., 2016). Aggressive behavior can be defined as an act directed towards a specific person, object or animal with the intent to hurt or frighten.

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Children present with more overt aggressive behaviors rather than covert and onset occurs more commonly in childhood rather than adolescence (Reebye & Moretti, 2005). Violence can be defined as the intentional use of threatened or actual, physical force or power against oneself or another person, which results in, or has a high likelihood of causing harm (World Health Organisation (WHO), 1991). As a behavioral construct, aggression is one of the core characteristics displayed for a diagnosis of CD in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) (American Psychiatric Association (APA), 2013). CD is often considered a diagnostic challenge in child and adolescent mental health, due to

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ACCEPTED MANUSCRIPT heterogeneity within the classification and including the high prevalence of comorbidities (Klahr & Burt, 2014). Youth aggression is a multifaceted phenomenon that is displayed differently depending on age and gender (Halperin, McKay, & Newcorn, 2002). Several points need to be considered before identifying aggressive behavior as a disorder, such as the differentiation between prosocial assertive play as opposed to behaviour with the intent to

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hurt or frighten. Aggressive symptoms may change with developmental competence in

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motor and cognitive domains. For example, preschool aged children may display instrumental and physical expressions of aggression whereas, school-age children may

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exhibit hostile aggression through name-calling, criticizing and ridiculing (Reebye, 2005).

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In the context of intervention monitoring and evaluation studies, there is a requirement to distinguish between normal and abnormal levels of violence and aggression, and the

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nature and quality of the behaviors that fall outside of typical development expectations (Halperin, McKay, Grayson, & Newcorn, 2003).

Behavior rating scales are instruments used to complete a relatively quick, normative-

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based assessment of child behavior. They can be used to measure clinical outcomes such as the

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efficacy and safety of an intervention, and/or patient related factors that may influence the success of intervention (e.g., adherence, social environment, quality of life) (Hunsley & Mash,

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2010). In clinical research practitioner assessments are limited by lack of inter-rater and testretest reliability, difficulties standardizing clinical knowledge and experience, as well as cost

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and time constraints (Slade, Thornicroft, & Glover, 1999). For the purpose of outcome measurement in clinical research, the use of assessment tools or instruments are often employed. They are often formal, structured instruments, that demonstrate psychometric properties such as reliability and validity (Slade et al., 1999). Use of a statistically reliable instrument, appropriately selected based on its applicability to the population being studied and the types of questions being asked, is essential for effective research (Suris et al., 2004). There is a need to identify appropriate instruments for use in violent and aggressive youth particularly as there are reports of unstandardized instruments with unclear

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ACCEPTED MANUSCRIPT psychometric properties being used in contemporary research (Elson, Mohseni, Breuer, Scharkow, & Quandt, 2014). Multiple instruments are available for the diagnosis and assessment of CD in youth, including those that assess CD and other behavioral symptoms and comorbidities (i.e., broadband), and those that are violence and aggression specific (i.e., narrow-band) (Farmer et al., 2016; Hersen, 2006). However, in clinical research it is useful if the instrument measuring

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aggression and violence can assess the frequency and or severity of problem behaviors

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(Halperin et al., 2002). Although pharmacotherapy is seldom first-line in the management of violent and aggressive behaviors in youth, numerous classes of medications have been

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documented with the large majority only supported by anecdotal evidence and exploratory investigation (Hambly, Khan, McDermott, Bor, & Haywood, 2016). A review investigating the

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role of pharmacotherapy in CD revealed that no particular instrument was a ‘gold-standard’

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measure of outcome to evaluate violent and aggressive behaviors in youth receiving pharmacological intervention (Hambly et al., 2016). It was therefore evident that there is a need to identify the most appropriate standardized instruments for pharmacotherapy intervention

1.2.1

METHODS

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1.2

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efficacy research involving youth with violent and aggressive behaviors.

Search strategy

A review evaluating the psychometric, administrative and practicality evidence of

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instruments in pharmacotherapeutics efficacy studies in youth with violence and aggression was

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conducted. Firstly, instruments utilized to evaluate efficacy of intervention in randomised controlled trials (RCTs) of pharmacotherapy in the management of CD and its related comorbidities in youth were included based on the findings from the most recently published systematic review (Hambly et al., 2016). The studies were published in English from January 2000 to an updated search till January 2016. Secondly, the name of the instrument and the key words ‘validity’, ‘reliability’, ‘children’, ‘adolescents’, and ‘youth’ were used to search for literature in MEDLINE, OVID SP and EMBASE. Literature for each tool was investigated for evidence of, or instrument specific information pertaining to, the criteria listed in summary Table 1. Additional literature was identified through searching reference lists of papers 5

ACCEPTED MANUSCRIPT identified after initial screening. For the analysis of validity and reliability, the search focused on the use of the instruments in youth populations who displayed violent and/or aggressive behavior. The titles and abstracts of all articles identified were screened independently by two review authors (JH and SK). If conflicting opinions arose during screening, a third author (AH) determined if inclusion in the study was appropriate. 1.2.2

Scoring

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1.2.2.1

Psychometric and administrative evaluation

Scoring criteria for psychometric and administrative properties for each instrument is

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outlined below. Retrieved information was graded on a 3-point scale adapted from the Scientific

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Advisory Committee’s Instrument Review Criteria (Lohr et al., 1996) by (Andresen, 2000). Generally, an instrument displaying high quality evidence for the evaluated characteristic was

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awarded an ‘A’ grade. A ‘B’ grade was given if it displayed moderate quality, a ‘C’ grade if it had poor quality, and an unknown (‘U’) grading if no information was available. To rank the

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instruments, a numeric score was assigned to the alphabetical grades as follows: U=0, A=1, B=2, C=3. Reliability

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1.2.2.2

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Reliability refers to the degree to which an instrument consistently produces the same result at different times, from independent observers, and/or different samples (Wasserman & Bracken, 2003). There are three general classes of reliability used when evaluating instruments: Inter-Rater/Observer Reliability - assesses the degree to which independent interviewers

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give consistent estimates using identical instruments (Roberts & Priest, 2006); Test-Retest Reliability - assesses the consistency of results from two separate

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

administrations of an instrument, to the same participants (Roberts & Priest, 2006); 

Internal Consistency Reliability - assesses the consistency to which items in a given instrument, domain, or sub-test are grouped correctly. This is often measured by Cronbach’s coefficient alpha (Cicchetti, 1994; Cronbach, 1951);

For the purpose of inter-rater and test-retest reliability scoring an intraclass correlation coefficient (ICC) or kappa coefficient (κ) ≥0·80 was considered excellent (graded ‘A’), <0·60 considered poor (graded ‘C’), and between these ranges (≥0.60, <0.80), moderate

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ACCEPTED MANUSCRIPT (graded ‘B’) (McHugh, 2012). For internal consistency of scales a Cronbach’s alpha (α) or Kuder-Richardson Formula 20 (KR-20) ≥0·80 scored excellent (‘A’), ≥0·70 and 0·80 adequate (‘B’), and <0·70 low or inadequate (‘C’).(Andresen, 2000; Endicott, Tracy, Burt, Olson, & Coccaro, 2002) 1.2.2.3

Validity An instrument is considered robust in validity if there is strong evidence and theory that

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support the appropriateness, meaningfulness, and usefulness of test results and interpretation (Colliver, Conlee, & Verhulst, 2012). If the multitrait-multimethod matrix (MTMM) and/or

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correlation coefficient were used for the assessment of convergent validity, the following scores

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were allocated, ‘A’ = strong correlation (≥0.60), ‘B’ = moderate correlation (≥0.30 and <0.60), and ‘C’ = weak correlation (<0.30) (Campbell & Fiske, 1959). The opposite scale for scoring

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was applied for discriminate validity, ‘A’ = ≤0.30, ‘B’ = <0.30 and ≥0.60, and ‘C’ = >0.60 (Campbell & Fiske, 1959). For factorial validity if root mean square error of approximation

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(RMSEA) ≤0.05, non-normed fit of index (NNFI) ≥0.95 or confirmatory factor analysis (CFI) ≥0.95 (Lecavalier, Aman, Hammer, Stoica, & Mathews, 2004) was obtained it was considered a

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good fit (‘A’). If RMSEA >0.05 and ≤0.08, NNFI or CFI ≥0.90 and <0.95 it was considered an

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acceptable fit (‘B’) and values outside of these ranges were considered poor fitting (‘C’). All other scores were allocated on face validity or statistical properties depending upon which

1.2.2.4

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method was used.

Sensitivity - responsiveness

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The sensitivity or responsiveness of an instrument refers to the ability to detect any small but meaningful changes due to an intervention (Andresen, 2000; Lim, Liong, Lau, & Yuen, 2015). Effect size and standardized response means are the two most common statistical measures for responsiveness (Lim et al., 2015). Values of effect size index and standardized response means of 0.5 or greater but less than 0.8 are considered a moderate effect and 0.8 or greater deemed as a large effect (Lim et al., 2015). If an instrument had evidence for responsiveness expressed as effect size and derived from longitudinal data with clearly identified population and documented time intervals it was awarded an ‘A’ rating. If there was

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ACCEPTED MANUSCRIPT weak evidence or it was based solely on statistical significance (p value) it was awarded a ‘C’. If evidence fell between these two extremes the instrument was rated a ‘B’. 1.2.2.5

Brevity – respondent burden Respondent burden is defined as the time, energy and demands placed upon those being

administered an instrument (Lohr et al., 1996). A maximum of 15 minutes is considered appropriate for a primary outcome measure (Andresen, 2000). The content should be

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appropriate for the target population and special training or resources should not be required. If a long questionnaire is warranted or particularly inconvenient, a study protocol should include

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compensation to reduce this burden e.g., payment (Andresen, 2000). Assessment of respondent

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burden may take the form of both quantitative and qualitative investigation. Quantitative assessment may include rating respondent satisfaction, whereas qualitative assessment may

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include reviewing respondent opinions and reactions (Andresen, 2000). A rating of ‘A’ was awarded for brevity (<15 minutes duration) and appropriate content. Grade ‘C’ was applied to

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instruments that were lengthy and had no evidence of appropriateness. Grade ‘B’ was awarded for those less than 30 minutes with some evidence of appropriate content. Simplicity – administrative burden

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1.2.2.6

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An administratively simple questionnaire is considered short, easily scored, without the need for a sophisticated computer program, and does not require specialist training or qualifications (Andresen, 2000; Lohr et al., 1996). If data gathered using the instrument was

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easily scored by hand, understood, inexpensive and required no formal training, it was awarded

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an ‘A’. If expensive, onerous for administration and scoring, and interpretation not straightforward, it was rated a ‘C’. Ratings falling between the 2 extremes ranked ‘B’. 1.2.2.7

Acceptability – cultural or language adaptations

The assessment of translation or cultural adaptation of an instrument involves two key criteria, ensuring conceptual and linguistic equivalence, and the evaluation of measurement properties (Lohr et al., 1996). To receive a high rating (‘A’) the instrument had evidence of validity for cultural adaptation and/or had information about methods to achieve linguistic equivalence (e.g., forward and backwards translations). If no evidence could be found for the

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ACCEPTED MANUSCRIPT validity and methodology of translation or adaptation a ‘C’ grade was awarded. If rated in between, the instrument was given a ‘B’ for acceptability. 1.2.2.8

Accessibility – alternative mediums The availability and assessment of alternative version in administration of instruments

(other than the original version) is a concept referred to as accessibility (Andresen, 2000; Lohr et al., 1996). To rate an ‘A’ for accessibility, instruments were available in multiple forms and

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found free of mode effects (i.e., no differences between the original version and transformed version upon administration). To rate a ‘B’ the instrument was available in other forms however

1.2.2.9

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forms or mode information available (Andresen, 2000).

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no testing for mode effects were evident. A ‘C’ grade reflected that there were no alternative

Conceptual model

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A conceptual model is a rationale for, and description of, the concept/s that the instrument is intended to assess and the relationship between those concepts (Lohr et al., 1996).

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For assessment, instruments were graded on how well they captured the intended conceptual framework. If an instrument carefully defined their measurement construct and domains, their

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grading reflected this. If domains were completely covered an ‘A’ was awarded, adequately

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covered attracted a ‘B’, and inadequately was given a ‘C’(Andresen, 2000). 1.2.2.10 Measurement model

A measurement model refers to an instrument’s scale and subscale structure, and the

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procedure followed to create scale and subscale scores (Lohr et al., 1996). For scoring an ‘A’ was awarded if there was no skewness or evidence for development of scoring, ‘B’ was awarded

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if there was skewness intermediate or conflicting evidence for development of scoring, and ‘C’ was awarded for substantial skewness (>20% of a groups scores at either extreme of a range) (Andresen, Rothenberg, Panzer, Katz, & McDermott, 1998) or no evidence for development of scoring. 1.2.2.11 Bias Instruments should not be affected by differences in culture, social circumstances, or impairment type, except for differences the tool intends to measure. Statistical methods such as Rasch Analysis or Confirmatory Statistical Analysis (CFA) can be used to assist with the detection of item and instrument bias, (Smith, 2004) however, a large proportion of grading 9

ACCEPTED MANUSCRIPT qualitative evidence of bias is somewhat subjective. For subjective grading an ‘A’ was awarded to instruments with clear evidence of review. A ‘B’ grade awarded if formal evidence was lacking but had good face validity for bias, and a ‘C’ grade was awarded if bias was evident. 1.2.3

Applicability to violence and aggression research

For practicality assessment, instruments were also evaluated independent of their psychometric properties, investigating the ability to measure violent and aggressive behaviors,

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and their frequency and severity. Instruments were further screened against the following questions:

Can the instrument be used to measure the frequency of violent behaviors?

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Can the instrument be used to measure the frequency of aggressive behaviors?

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Can the instrument be used to measure the severity of violent behaviors?

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Can the instrument be used to measure the severity of aggressive behaviors?

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How many items in the instrument measure violent behaviors?

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How many items in the instrument measure aggressive behaviors?

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Table 1 summarises the quality assessment criteria applied for instruments in the current

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systematic review.

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ACCEPTED MANUSCRIPT

Table 1: A summary of characteristics considered desirable for an appropriate standardized outcome measure Characteristic Reliability

Explanation

Criteria for Grading (Andresen, 2000; Lohr et al., 1996; McHugh, 2012)

Measurements by different observers, at different

Inter-rater/test-retest (ICC or κ)

Internal consistency (Cronbach α or KR-20)

times or in parallel ways produce the same result.

A = ≥0.80

A = ≥ 0.80

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B = ≥0.70, <0.80

B = ≥0.60, <0.80 C = <0.60 Validity

The instrument measures the intended outcome.

coefficient)

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A = ≥0.60

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B = ≥0.30, <0.60 C = <0.30 Responsiveness

degrees of change.

Brevity

Simplicity

Acceptability

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The instrument captures clinically meaningful

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The instrument length and content is appropriate.

E C

C A

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Convergent (correlation

C = <0.70

Factorial (RMSEA)

Factorial (CFI or NNFI)

A = ≤0.05

A = ≥0.95

B = >0.05, ≤0.08

B = ≥0.90, <0.95

C = >0.08

C = <0.90

A = Strong evidence with large effect size B = Moderate or conflicting evidence C = Weak evidence or based only on statistical significance, not effect size A <15 minutes and appropriate content B >15 minutes, <30 minutes and appropriate content C >30 minutes and/or inappropriate content

No formal training is required to use the

A = Inexpensive, no training, easy scoring and interpretation

instrument. It is easy and inexpensive to

B = Somewhat expensive, more obscure scoring and interpretation

administer, score and interpret. Ratings are clear.

C = Expensive and/or complex scoring and/or interpretation

Cultural and language adaptations of the

A = Validity evidence for translation and/or adaptation and methodology

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ACCEPTED MANUSCRIPT

instrument exist.

B = Evidence has some problems for translation and/or adaptation C = No evidence for translation and/or adaptation and methodology

Accessibility

The instrument is available and tested in different

A = Available in multiple forms, no mode effects

mediums e.g., computer, self-administration,

B = Available in multiple forms, no testing for mode effects

clinician interviews

C = No alternative forms or mode information

There is a rationale and description of the

A = Clearly defined measurement construct and domains

concept/s the instrument intends to assess, and the

B = Adequately defined measurement construct and domains

relationship between the concepts.

C = Inadequately defined measurement construct and domains

Measurement

The instrument captures detail and breadth that is

A = No skewness or evidence for scoring methodology

Model

intended

B = Skewness or intermediate/conflicting evidence for scoring methodology

Conceptual

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I R

C S U

N A

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C = Substantial skewness >20% in extreme range or no evidence for scoring methodology

Bias

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The instrument is not affected by differences in

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culture and social context.

A = Evidence of review for bias, no bias present B = Face validity, no formal evidence C = Bias evident

C C

A

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ACCEPTED MANUSCRIPT 1.3

RESULTS A total of 12 RCTs applied instruments for measuring efficacy of pharmacotherapy in

conduct disorders based on the recently published systematic review (Hambly et al., 2016). Twenty-four instruments were identified, of which 15 were excluded, based on their lack of aggressive and/or violent constructs, items assessing violent and/or aggressive behaviors, and published information. Seven instruments identified in the systematic review (Hambly et al.,

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2016) including the NCBRF (M.G. Aman, De Smedt, Derivan, Lyons, & Findling, 2002; Stocks, Taneja, Baroldi, & Findling, 2012), the Conners’ 3 (Connor, McLaughlin, & Jeffers-

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Terry, 2008), the BPI-01 (M.G. Aman et al., 2002; Ter-Stepanian, Grizenko, Zappitelli, &

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Joober, 2010), the ABC (M.G. Aman et al., 2002), the CBCL (Blader, Pliszka, Jensen, Schooler, & Kafantaris, 2010; Connor, Barkley, & Davis, 2000; Padhy et al., 2011; Steiner, Petersen,

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Saxena, Ford, & Matthews, 2003; Steiner, Saxena, et al., 2007; Wehmeier et al., 2011), the MOAS (Blader et al., 2010; Connor et al., 2008; Donovan et al., 2000; Malone, Delaney,

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Luebbert, Cater, & Campbell, 2000) and the SNAP-IV (Stocks et al., 2012; Wehmeier et al., 2011) met criteria for analysis (Figure 1). The CAS and the DBDRS were identified through

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properties (Table 2).

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reference searching. All nine instruments were scored based on psychometric and administrative

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24 instruments screened from 12 drug trials (RCTs) in CD (trial data extracted and evaluated from recently published systematic review) 8 instruments excluded (lacking aggressive/violent behavior constructs/items)

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Review of literature for reliability

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and validity studies for instruments

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Further 2 instruments identified from reference search

9 instruments excluded

criteria 8 records included - NCBRF

of included instrument)

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9 instruments evaluated against

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(insufficient data or previous version

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6 records included - Conners’ 3 6 records included - BPI-01

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2 records included - CAS

6 records included - ABC

5 records included - DBDRS

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7 records included - CBCL

6 records included - MOAS

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3 records included - SNAP-IV Figure 1: Selection of relevant instruments, presented as a flow diagram

1.3.1

Nisonger Child Behavior Rating Form (NCBRF) The NCBRF is designed to analyze the behavior of youth aged 3 to 16 with intellectual

disability and/or autism spectrum disorders (ASD) (Mircea, Rojahn, & Esbensen, 2010). It is a modified version of the Child Behavior Rating Form (CBCL) (Edelbrock, 1985) and has a teacher and a parent version (Mircea et al., 2010). A Typical IQ Version, has also been developed for rating children of normal developmental ability (M. Aman et al., 2008). The

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ACCEPTED MANUSCRIPT NCBRF consists of two key subscales (social competence and problem behavior), eight domains and 76 items (Michael G. Aman, Tassé, Rojahn, & Hammer, 1996; Tassé, Aman, Hammer, & Rojahn, 1996). The instrument is free to access and appears straight-forward to score. It exists in a psychometrically sound Romanian form (Mircea et al., 2010). Age and gender bias may be present for the conduct problems and insecure/anxious subscales (Tassé et al., 1996). Several psychometric studies have been conducted on the NCBRF that examined

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various forms of reliability and validity with mixed results (Mircea et al., 2010). For reliability,

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internal consistency was rated high for both parent (Cronbach α = 0.85) and teacher forms (Cronbach α = 0.87) in the problem behaviors subscale (Michael G. Aman et al., 1996). For the

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social competence subscale internal consistency was moderate for parent reports (Cronbach α =

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0.78) and high for teacher reports (Cronbach α = 0.84) (Michael G. Aman et al., 1996). Moderate inter-rater reliability was shown (median correlation coefficient = 0.51) between

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parents and teachers in the problem behaviors subscale which was accountable based on the different situational contexts of the raters. For validity, confirmatory factor analysis (CFA) found that the factor structure of the social competence subscale was acceptable (RMSEA =

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0.056), however the problem behavior section may be suboptimal (RMSEA = 0.086) (Norris &

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Lecavalier, 2011) findings which were also echoed in ASD youth (Lecavalier et al., 2004). Comparison with the Aberrant Behavior Checklist (ABC) provided support for both parent

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(median correlation coefficient = 0.72) and teacher (median correlation = 0.69) versions for convergent validity (Michael G. Aman et al., 1996). Additionally, parent-ratings for the conduct

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problems subscale compared with the Disruptive Behavior Checklist – Disruptive/Antisocial subscale further supported convergent and criterion validity (Norris & Lecavalier, 2011). 1.3.2

Conners’ 3rd Edition The use of Conners’ behavioral rating scales have been long documented; with the

current edition being the Conners’ 3 (Conners, 2010; Westerlund, Ek, Holmberg, Naswall, & Fernell, 2009). There is a multitude of published literature on previous editions of the scales, with well-established validity and reliability evidence (Conners, Sitarenios, Parker, & Epstein, 1998; Waschbusch & Elgar, 2007). The 57 questionnaire items in Conners’ 3 are based largely on the DSM (American Psychiatric Association (APA), 2013) and principles of the International 15

ACCEPTED MANUSCRIPT Statistical Classification of Diseases (Westerlund et al., 2009; World Health Organisation (WHO), 1991). They assess ADHD, common comorbidities (e.g., ODD and CD) and associated problem behaviors in youth aged 6 to 18 (Conners, 2010). Connors’ 3 items are rated on a 4point Likert scale where higher scores are associated with a greater number and/or frequency of concerns (Conners, 2010). Three different scales can be used to analyze behavior in the Conners’ 3 namely, the Content Scales, DSM Symptom Scales and the Validity Scales. Flexible

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administration by qualified professionals is available, in online, offline and written modes;

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offered in 3 forms (parent, teacher and a self-report) (Conners, 2010). The instrument is expensive (~$650AUD) and appears complex to score either by hand or computer (Conners,

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2010). However, scoring is weighted for age and gender (Conners, 2010). There is a lack of published evidence for Conners’ 3 and its DSM-V version, perhaps due to the regularity of its

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updates. Overall the Conners’ 3 had high quality evidence for reliability with data for internal

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consistency (parent Cronbach α = 0.91, teacher Cronbach α = 0.94, self-report Cronbach α = 0.88), (Conners, 2010) inter-rater, and test-retest reliability (Conners, 2010). There are reports for moderate to high validity through multiple statistical analyzes, although not all data was

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reported (Conners, 2010). It has been translated into other languages including French, (Catale,

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Geurten, Lejeune, & Meulemans, 2014; Fumeaux et al., 2016) Chinese (Xiao, 2012) and Spanish, however published methods for translation methodology are lacking (Conners, 2010). The Behavior Problems Inventory (BPI-01)

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1.3.3

The Behavior Problems Inventory (BPI-01) is a 52-item instrument used to evaluate

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self-injurious, stereotypic, and aggressive/destructive behavior in mental retardation and other developmental disabilities (Rojahn, Matson, Lott, Esbensen, & Smalls, 2001). The evolution of the BPI-01 has been extensively documented over the years with well-defined measurement construct and domains (Rojahn et al., 2001). It has been transformed since its first German version in the 1980s and undergone multiple revisions (Rojahn, 1984; Rojahn et al., 2001). The BPI-01 has been translated into 11 languages (Mircea et al., 2010). Studies have examined the psychometric properties of the BPI-01 across children and adults samples (Rojahn et al., 2013). A comprehensive analysis of the BPI-01 in 1122 adults and children with intellectual disabilities (mean age = 34.4 years) from several sites reported moderate to high internal consistency across 16

ACCEPTED MANUSCRIPT frequency and severity of all three subscales (Cronbach's α = 0.73 to 0.92) (Hastings et al., 2012). Furthermore, a study including participants 14 to 91 years old found moderate (ICC = 0.64 to 0.76) test-retest reliability for the BPI-01 (Rojahn et al., 2001). Evidence for strong convergent and discriminant validity has also been reported, with factor structure endorsed by confirmatory factor analysis (Matson, Wilkins, Boisjoli, & Smith, 2008; Rojahn et al., 2012). In addition, several studies have found supporting evidence for criterion-related validity of the

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BPI-01 with the Repetitive Behavior Scale Spearman correlation = 0.77 (self-injurious), 0.68

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(stereotyped behavior) (Rojahn et al., 2010) and the Aberrant Behavior Checklist in adults (Rojahn, Aman, Matson, & Mayville, 2003).

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Few studies have exclusively assessed the use of the BPI-01 in youth. A study of 237

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ethnically diverse youth (four to 22 years old) with severe developmental disabilities and/or behavioral challenges supported the validity and reliability of the BPI-01 in this population

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(Rojahn et al., 2010). For the BPI-01 the mean teacher-teacher single measures and test-retest reliability was moderate to excellent with ICC = 0.76 and ICC = 0.84, respectively. For internal consistency, reliability coefficients ranged from low to high across the three subscales

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(Chronbach’s α = 0.86 (stereotypic), 0.88 (aggressive/destructive), 0.59 (self-injurious))

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(Rojahn et al., 2010). Further, excellent internal consistency for frequency (Chronbach’s α = 0.87) and severity subscales (Chronbach’s α = 0.89) and test-test reliability has been reported in

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infants and toddlers at risk for intellectual or developmental disabilities (Rojahn et al., 2013). The BPI-01 has also been found to have high convergent and discriminant validity when

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compared to the Nisonger Child Behavior Rating Form (NCBRF), as well as adequate factorial validity in youth (Rojahn et al., 2010). 1.3.4

The Children’s Aggression Scale (CAS) The CAS is designed to evaluate setting-specific (i.e., home and school) frequency and

severity of aggressive acts of non-institutionalized youth ages 5 to 18 years (Halperin et al., 2003). Two English versions exist, a parent and a teacher version. The parent version features 33 items, and the Teacher Rating Form features 23. The CAS features 5 key domains namely verbal aggression, aggression against objects and animals, provoked physical aggression, unprovoked physical aggression, and use of weapons. The Parent Rating Form has two 17

ACCEPTED MANUSCRIPT additional domains including, aggression against family members, and aggression against nonfamily members (Halperin et al., 2002). The items in the CAS are weighted differentially depending on the severity of the act (Halperin et al., 2002). The CAS requires evidence of qualifications for use, and has sophisticated hand or computer-assisted scoring. Despite this, it has high internal consistency for both the parent (Cronbach’s α = 0.93) and teacher (Cronbach’s α = 0.93) versions (Halperin et al., 2002). Differentiation between the diagnostic subgroups of

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ADHD, ODD and CD and correlations with other instruments including the CBCL provide

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support for validity (Halperin et al., 2002). The teacher and parent versions both display moderate to high convergent validity (Halperin et al., 2003; Halperin et al., 2002). The parent

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version has a good measurement model with a one-way analysis of variance (ANOVA)

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indicating significant difference in ratings across all 5 domains, with a continuum of severity also emerging (Halperin et al., 2002). Bias was not formally investigated however in reliability

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and validity studies featured an ethnically diverse population (Halperin et al., 2002). In the context of youth with violent and aggressive behaviors, 100% of the items in the CAS focus on aggression and violent outbursts, rendering it a valuable tool in CD clinical research. Aberrant Behavior Checklist (ABC)

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The Aberrant Behavior Checklist (ABC) is a 58-item instrument used to measure behavior problems of children and adults with mental retardation across five subscales (Rojahn

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et al., 2003). It exists in two forms, residential and community (ABC-C) (M. G. Aman, Singh, Stewart, & Field, 1985; Schmidt, Huete, Fodstad, Chin, & Kurtz, 2013). It has an excellent

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measurement model with in-depth reporting of its development (Marshburn & Aman, 1992). The ABC is, or currently is, undergoing translation into 39 languages as reported by its distributors (M. G. Aman, 2012). However, minimal information for translation methods and validation was retrieved. Psychometric studies in toddlers have shown that the ABC-C is a reliable and valid behavior-rating instrument. Overall, moderate to high internal consistency for each subscale across two studies (Chronbach’s α ranging 0.68 to 0.90 (Karabekiroglu & Aman, 2009) and Chronbach’s α ranging 0.81 to 0.96 (Rojahn et al., 2013) has been demonstrated. Moderate convergent validity has been displayed in clinician-rated youth with intellectual disabilities and challenging needs (Hill, Powlitch, & Furniss, 2008). Furthermore, high 18

ACCEPTED MANUSCRIPT convergent validity with the CBCL has been reported in outpatient psychiatry clinics in toddlers with a variety of conditions (Karabekiroglu & Aman, 2009). The ABC-C contains less than 10% of items that specifically measure violent and aggressive behaviors. However, studies to validate the instrument have included participants with primary diagnoses of aggressive and/or violent behavior such as CD (Karabekiroglu & Aman, 2009; Rojahn & Helsel, 1991). 1.3.6

The Disruptive Behavior Disorders Rating Scale (DBDRS)

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The current DBDRS is based on the fourth edition of the DSM (Loona & Kamal, 2011). It consists of 41 items representing four domains of symptoms for CD, ODD and ADHD

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(Pelham, Gnagy, Greenslade, & Milich, 1992). There are two scoring methods than can be used

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to assign a DSM diagnosis to the child (Pelham et al., 1992). The DBDRS has been translated into Dutch (Antrop, Roeyers, Oosterlaan, & Van Oost, 2002), Spanish (Silva et al., 2005) and

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Urdu (Loona & Kamal, 2011). The Urdu version has displayed adequate psychometric properties, demonstrating that it is reliable for screening and diagnosis in the school and home

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setting (Loona & Kamal, 2011). In the same study, the internal consistency reliability for the English version of the DBDRS ranged from moderate to high (Chronbach’s α = 0.70 to 0.92)

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(Loona & Kamal, 2011). Furthermore, another study of teacher responses showed excellent

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internal consistency reliabilities for the DBDRS (Chronbach’s α = 0.91 to 0.95) across the inattentive (Chronbach’s α = 0.93), hyperactive/impulsive (Chronbach’s α = 0.91), and

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oppositional defiant (Chronbach’s α = 0.94) subscales (Pelletier, Collett, Gimpel, & Crowley, 2006). High convergent validity of the DBDRS with the School Situations Questionnaire (SSQ)

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has been found in teacher responses in preschool aged children (Pelletier et al., 2006). Low agreement between parent and teacher ratings had highlighted potential instrument bias (Antrop et al., 2002; Silva et al., 2005). Further studies evaluating the psychometric properties of the DBDRS are recommended as its role in the context of violent and aggressive behavior rating has not been fully understood. Investigation into specific teacher and parent versions is also warranted, although it was unclear to determine if separate versions existed, with a report that the teacher version excluded the CD domain (Pelletier et al., 2006).

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ACCEPTED MANUSCRIPT 1.3.7

The Child Behavior Checklist (CBCL) The CBCL is a 120 item parent-report, which provides a measure of behavioral and

emotional functioning and social competence of youth, aged six to 18 (Achenbach, 1991). The CBCL has been updated to include DSM-oriented scales, and to complement the new preschool version for children aged 18 months to 5 years. The CBCL has two domains of open and closed questions, social competence and problem behaviors (Siddons & Lancaster, 2004). These

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domains can be further divided into DSM-orientated scales, (Nakamura, Ebesutani, Bernstein, & Chorpita, 2009) eight syndrome structures, or ratings of externalising/internalising behaviors

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(Ivanova et al., 2007). Parents rate each closed question on a three-point Likert scale (higher

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scores indicating a greater number of behaviors present) based on the preceding 6 months (Ivanova et al., 2007). The CBCL is part of a multi-informant group of instruments developed

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by Achenbach and colleagues which also includes the Youth Self Report and the Teachers Report Form (Ivanova et al., 2007). Professional qualifications are required to access the costly

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(~$700AUD) instrument and scoring is completed digitally or by hand (Sawyer et al., 2000a). Raw scores, T-scores and thresholds can be used to summarise the CBCL in multiple ways

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under different scales, syndromes and structures (Sawyer et al., 2000a). The CBCL User

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Manual reports high inter-rater reliability (ICC =0.93, p<0.001) and test-retest reliability (ICC =0.95, p<0.001) for item scores (Achenbach, 1991). It is also reported in the manual that there is

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established evidence for content validity, criterion-related validity and construct validity for the CBCL (Achenbach, 1991). Published evidence supports clinician use of the CBCL

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demonstrating moderate reliability (mean Chronbach’s α = 0.77), convergent and discriminant validity and sound factorial structure (CFI = 0.92) compared to parent-reporting for the CBCL (Dutra, Campbell, & Westen, 2004). The CBCL also demonstrates moderate to high factorial validity for the eight syndrome structure (RMSEA = 0.026 to 0.055) across 30 societies, with 58 051 participants aged six to 18 (Ivanova et al., 2007). Findings also support the concurrent validity of the recently derived DSM-oriented scales (Ebesutani et al., 2010). Due to the multiple structures and subscales, analysis of the conceptual and measurement models of the instrument in regards to its use in violent and aggressive youth has not been conducted. The CBCL features few items (approximately 3.3% of the instrument) related to violent or 20

ACCEPTED MANUSCRIPT aggressive outbursts, limiting its usefulness in studies featuring these participants. However, it is useful for obtaining data on the range of comorbidities that often need to be reported or included in the analysis in CD studies. Further research including youth with violent and aggressive behavior, or those examining the conduct subscale of the CBCL may be useful to determine the role of this instrument in the CD population. 1.3.8

Modified Overt Aggression Scale (MOAS)

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The MOAS is a 16 item rating scale that measures aggressive behavior over four domains (Kay, Wolkenfeld, & Murrill, 1988; Sorgi, Ratey, Knoedler, Markert, & Reichman,

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1991). The items of the MOAS are hand-scored on a 5-point Likert scale of increasing severity

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with verbal aggression assigned the lowest weight and physical aggression the highest (Huang et al., 2009). The total weighted score may range from 0 to 40, with higher scores indicating

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more aggression (Dean, Bor, Adam, Bowling, & Bellgrove, 2014). The MOAS has evidence for validity and reliability in French (Cronbach’s α of 0.84 to 0.89 (De Benedictis, Dumais,

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Stafford, Cote, & Lesage, 2012)) and Chinese (Huang et al., 2009) (ICC = 0.94, p<0.001 (Huang et al., 2009)) versions however both studies lacked information regarding their

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methodology to achieve linguistic equivalence. The validity and reliability of the MOAS has

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been described in multiple inpatient and outpatient populations including intellectual disability, behavioral disorders and brain injuries (De Benedictis et al., 2012; Endicott et al., 2002; Huang

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et al., 2009; Kho, Sensky, Mortimer, & Corcos, 1998; Oliver, Crawford, Rao, Reece, & Tyrer, 2007). Reports of acceptable to high reliability and validity in multiple studies exist, however

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studies including children are lacking. Dean et al.,(Dean et al., 2014) report that the validity of the MOAS has been examined in several studies, and demonstrated reliability and sensitivity in children, however, there is minimal evidence of published studies. Despite this, the tool has been used as an outcome measure in many studies with child and adolescent participants (Blader et al., 2010; Dean et al., 2014; Kronenberger et al., 2007). All items in the MOAS focus on aggressive and violent outbursts, with the potential to be a valuable tool in CD clinical research. Further studies to validate the psychometric properties of the MOAS in children and adolescents are recommended.

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ACCEPTED MANUSCRIPT 1.3.9

The Swanson, Nolan and Pelham Teacher and Parent Rating Scale (SNAP-IV) The 90 item SNAP-IV Rating Scale is a revision of the SNAP Questionnaire designed

to measure ADHD and ODD symptoms in children and young adults (Gau et al., 2009). Items 41 to 90 of the SNAP-IV contain criteria from other DSM-IV disorders such as CD, generalized anxiety disorder, and intermittent explosive disorder. These are often symptoms that overlap with ADHD, or may be comorbid disorders (Inoue et al., 2014). The SNAP-IV can be accessed

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online. Hand scoring appears simple. The SNAP-IV has been used in multiple clinical trials as a measure of efficacy and ADHD symptom severity (Bussing et al., 2008). One study using the

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SNAP-IV has reported moderate to high internal consistency (Stevens, Quittner, & Abikoff,

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1998). There are also published data to support the validity and reliability of the SNAP-IV for the Japanese (Inoue et al., 2014) and Chinese (Gau et al., 2009) versions. The SNAP-IV has

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been criticized for the lack of published psychometric properties and sparse normative data in a review of ADHD rating scales, limiting its usefulness in research and clinical practice (Collett,

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Ohan, & Myers, 2003; Gau et al., 2009). For the same reason, it was not possible to extensively review this instrument for its use in violent and aggressive youth. Furthermore, the SNAP-IV

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only features a handful of symptoms (approximately 9% of the instrument) indicative of violent

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or aggressive outbursts, limiting its usefulness. Out of the nine instruments, two (NCBRF and ABC) can be used to evaluate behaviors

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in those with low IQs or mental retardation. Both the ABC and BPI-01 can be used to rate behaviors across child and adult populations and it is unknown if scoring is adjusted for age and

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gender as there was lacking published information regarding their measurement models. Numbers of items in the instruments varied from 16 (MOAS) to 120 (Conners’ 3rd Edition). Periods of measured behavioral occurrences spanned from the present (CBCL) to the past year (CAS). Instruments ranged in cost from free-access to $650AUD (see Appendix). Responsiveness data were not obtained for any instrument. The NCBRF, Conners’ 3rd Edition, and the BPI-01 were rated the highest for their psychometric properties. The CAS, ABC-C, and the DBDRS were rated moderately, and the CBCL, MOAS and SNAP-IV were rated lowest (Table 4). The NCBRF, BPI-01 and CAS were the only instruments that can be used to measure

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ACCEPTED MANUSCRIPT both frequency and severity of behaviors. The CAS and MOAS featured the most items

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pertaining to aggression (both 100%).

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Table 2: Ranking of Assessed Tools Based on Psychometric and Administrative Properties Psychometric Properties

Instrument

Reliability

Validity

Responsiveness

Conceptual

Administrative Properties

Measurement Model

Bias

Brevity

Simplicity

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Nisonger Child Behavior Rating

3

2

0

3

3

3

2

0

2

2

3

2

0

3

C S U

1

Behavior Problems

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Inventory (BPI-

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01) Children’s Aggression 3

C C

2

0

Scale

3

3

23

1

2

1

2

3

20

2

2

2

3

3

1

19

3

N A

M

Score

3

3

2

2

1

1

1

18

4

3

0

2

2

2

1

2

17

5

A

(CAS) Aberrant Behavior

0

Rank

3

3

Edition

Total Accessibility

2

Form (NCBRF) Conners’ 3rd

T P

Acceptability

3

2

0

Checklist (ABC)

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Disruptive Behavior 3

2

0

2

0

1

3

2

3

1

17

5

3

3

16

6

Disorder Scale

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(DBDRS)

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Child Behavior Checklist

2

2

0

0

0

3

2

C S U

(CBCL) Modified Overt

N A

Aggression 0

0

0

3

3

0

Scale (MOAS)

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Swanson, Nolan, and Pelham 0

0

T P E

0

Rating Scale (SNAP-IV)

2

0

1

3

3

2

2

16

6

3

3

3

1

12

7

M

0

C C

3=A, 2=B, 1=C, 0=Unknown

A

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ACCEPTED MANUSCRIPT Table 3: Ranking of Instruments and Applicability to Violence and Aggression Research Number

Rank

Measures

Measures

Psychometric

frequency

severity

Instrument

Comments

of items n (%)

Nisonger Child

Designed for use in ~7

Behavior Rating

1

Yes

those with sub-

Yes (9.2)%

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Form (NCBRF) Conners’ 3rd

average IQ

Lacking published

Edition

2

Yes

No

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~15

data for DSM-V

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(13.6%)

Inventory (BPI-01) 3

(CAS)

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Aberrant Behavior

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Aggression Scale

Yes

11

designed for use in (21.2%)

average IQ

33

100% of scale

(100%)

measures aggression

Yes

Developed and ~5

5

No

standardized in

Yes (8.6%)

adults

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Checklist (ABC)

4

for scoring lacking,

those with sub-

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Children’s

Published methods

Yes

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Yes

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Behavior Problems

Disruptive

Behavior Disorder

version

Extensive published 15

5

No

data for ADHD

Yes (33.3%)

Scale (DBDRS)

populations

Child Behavior

Part of a multi~4

Checklist (CBCL)

6

Yes

informant group of

No (3.3%)

instruments Modified Overt

6

No

Yes

16

Lacking validation

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Aggression Scale (MOAS)

in youth populations, 100% of scale measures aggression

Swanson, Nolan,

Published

and Pelham Rating 7

No

~8

psychometric and

(8.8%)

normative data

Yes

lacking

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Scale (SNAP-IV)

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ACCEPTED MANUSCRIPT 1.4

DISCUSSION The strengths and weaknesses of the reviewed instruments will be discussed under the

following subheadings: instruments accounting for the heterogeneity of aggression and comorbidities of conduct disorder, instruments encompassing weighted scoring for gender differences, Instruments accounting for the severity and frequency of aggressive behaviors, instruments accounting for average and sub-average IQ, impact of technological advances on

1.4.1

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instruments and their development, and practicality, findings and recommendations. Instruments accounting for the heterogeneity of aggression and comorbidities of

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conduct disorder

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The assessment of violence and aggression using behavior rating tools still appears limited, with a predominate focus on oppositional and defiant behavior, rather than aggression

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itself (Halperin et al., 2002). Instruments that intend to measure aggression were frequently confounded by items that evaluate oppositional and defiant behavior, perhaps due to the

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heterogeneity and frequency of comorbidities in those with CD (Halperin et al., 2002; Klahr & Burt, 2014). The CAS and the MOAS take into consideration the heterogeneity of aggressive

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behaviors featuring items to rate multiple subtypes of aggressive behaviors. The CAS also

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considers the context of the behavior whether it occurs in the home, out of the home, between peers, between siblings, and has the option of multi-informants (teacher version or parent version).

Instruments encompassing weighted scoring for age and gender differences

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1.4.2

The display of violent and aggressive behaviors has different implications based on the

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age and gender of the aggressor (Halperin et al., 2002). The CAS, Conners’ 3rd Edition, CBCL and DBDRS all feature scoring systems that take into account weighted and/or standardized adjustments. Scoring systems that weight more severe acts more heavily than less severe acts may provide a more accurate evaluation of the problem behaviors (Hirsch, Frank, Shapiro, Hazell, & Frank, 2004). Standardising behavior for age and gender can lead to scores that can be compared to age and gender-appropriate ranges, aiding in the delineation of normative and non-normative behaviors (Steiner, Remsing, & Work Group on Quality, 2007). The BPI-01 and ABC are instruments that can be used in adults. There was minimal published information found about the scoring system for the BPI-01. It was not able to be 28

ACCEPTED MANUSCRIPT determined if the age of subjects was taken into account during its development which may limit its usefulness and be a potential source of bias. There is a further need for evaluating instruments not standardized in youth, since the presentation of their behaviors may differ from adults as a result of developmental factors (Schmidt et al., 2013). 1.4.3

Instruments accounting for the severity and frequency of aggressive behaviors The ability to assess severity independent of frequency of behaviors is an important and

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valuable characteristic. Instruments that do not feature weighted scoring or combine frequency and severity are problematic (Halperin et al., 2002). Weighting items depending on the severity

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of the act allows for more severe episodes of behavior to be mathematically weighted more

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heavily than less severe ones (Halperin et al., 2002). The NCBRF, BPI-01, and CAS were the only instruments that both measured frequency and severity of behaviors. The BPI-01 measures

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frequency and severity of behaviors independently, however published scoring methods are lacking. The NCBRF requests users to rate behavior over the past month, however combines

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frequency and severity rating for each item The CAS requests users to rate behavior over the past year and provides items that escalate in severity. The items are then rated on a five-point

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Likert scale for frequency. Although there is concern over the lack of precision when estimating

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frequency, using a quantitative approach (e.g., “never”, “once a month”, “most days”) may overcome error variance that is associated with the users’ perception of subjective terms such as

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“occasionally” and “often” (Halperin et al., 2002). The CAS was the only scale that weighted various acts of aggression to determine the severity of specific acts of aggression beyond the

1.4.4

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frequency.

Instruments accounting for average and sub-average IQ The assessment of learning disabilities is essential in individuals with conduct problems

as a third of children with CD have sub-average IQ (Scott, 2012). Longitudinal studies show those with early onset CD have lower IQ and are predicted to have poorer outcomes in adulthood (Lahey et al., 1995; Scott, 2012). The BPI-01 as well as the NCBRF are designed to measure subjects with sub-average IQ. The NCBRF has a recently developed “Typical IQ” version, however it is unknown if the BPI-01 is suitable to use in this group. Although the BPI01 ranked highly in this review it should be used carefully in those with typical IQ until further 29

ACCEPTED MANUSCRIPT validation can be determined. Instruments should be used with caution until validated for use in those with typical IQ and sub-average IQ. 1.4.5

Impact of technological advances on instruments and their development The emergence of technologically advanced instruments is an area of interest. The

electronic Hamilton Anatomy of Risk Management tool (e-HARM) has recently been released and is a free electronic instrument that monitors a patient to help predict the likelihood of

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violent and aggressive outbursts (Vogel, 2016). The instrument aggregates and charts captured data over time, while connecting to past episodes and treatments. New technology may

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revolutionize how aggression is measured, monitored, and managed (Vogel, 2016). Therefore, it

1.4.6

Practicality, findings and recommendations

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should be considered when developing new, or refining existing instruments.

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Overall, it became apparent that aggressive behaviors typically receive relatively little attention in broad-band behavior rating instruments with small numbers of designated items,

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often confounded and conflated with oppositional and defiant symptoms (Rojahn et al., 2001). The two instruments that ranked highest, NCBRF and Conners’ 3rd Edition (presented in Table

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3), were broad-band behavior rating scales that only had approximately 9.2% and 13.6% of

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items measuring violent and aggressive behaviors, respectively, limiting their usefulness. The CAS is a psychometrically sound instrument that takes into account frequency and severity of behaviors as well as age and gender effects thus, is recommended for use in this violent and

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aggressive youth research. All of the items in the CAS and the MOAS can be used to measure

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violent and/or aggressive behaviors. Further research into the psychometric properties of the MOAS in violent and aggressive youth is required before its use can be recommended.

1.5

CONCLUSION Although broad-band scales such as the NCBRF and Conners’ 3rd Edition rated

highest for their psychometric properties, their usefulness in youth violence and aggression research is limited. This has led to conclude that much of the diversity in predictor and criterion measures may be due to a fundamental lack of theoretical models considering the heterogeneity of CD. In order to measure the efficacy of a pharmcotherapeutic intervention in those with violence, aggression and/or CD, age, 30

ACCEPTED MANUSCRIPT gender, functional level, situational context and the type of informant should also be taken into account. Most behavior rating instruments contain few designated items specific to violent and aggressive behaviors and are often conflated with oppositional and defiant symptoms. All of the items in the CAS and the MOAS can be used to measure violent and/or aggressive behaviors. Further research into the psychometric properties of the MOAS in violent and aggressive youth is required before its use can be recommended. The

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CAS was found to be the most psychometrically sound and useful instrument that

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exclusively measures aggressive behaviors in youth.

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ACKNOWLEDGEMENTS We thank Griffith University for partially funding this study. The study has not received

any funding from third parties. Conflict of interest: The authors declared no potential conflicts of interest with respect to the research,

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authorship, and/or publication of this article.

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ACCEPTED MANUSCRIPT APPENDIX Features of Included Instruments

Measures

Numb

Dom Time

Questi

Age

Cos

er of

ains

on

(years

t

items

or

types

)

($A

(time

Subs

UD

to

cales

)

measured

PT

Name

RI

compl

e 201

problem behaviours

Behavio

and social

ur

competence in

Rating

children with low

Form

IQs/mental

(NCBR

retardation.

’ 3rd Edition

Over the

Closed

past

and 1

month (for

open

6 3-16

0

Closed

6-18

650

Closed

5-18

380

closed questions); 1-2 months for open questions.

Behaviours

110

associated with

(20

conduct and

minute

aggression in

s)

AC

Conners

CE

F)

8

MA

r Child

76

D

Parent assessment of

PT E

Nisonge

NU

SC

ete)

Jun

7

Past month

ADHD +/CD/ODD. Children

Parent observed

33

’s

frequency and

(Parent

5

Past year

and 2

39

ACCEPTED MANUSCRIPT Aggressi

severity of

), 23

open

on Scale

aggressive and

(Teach

(CAS)

disruptive

er)

behaviours.

(10-15 minute s)

ur

in residential/

Checklis

community/

t

educational settings

(ABCC) Behavioural and

Behavio

emotional

ur

functioning and

minute

Checklis

social competence

s)

Behavio

PT E

2

(15-20

173

adult, eviden ce lackin g for <5yrs old46

Present to

Open

6-18

6 months

and

years

180

closed

CE AC

6-18

120

D

Child

Child to

MA

nity)

(CBCL)

Closed

available

(Commu

t

Not

PT

problem behaviours

5

RI

Behavio

58

SC

Mental retardation

NU

Aberrant

Self-injurious,

52

3

2 months

Closed

Childr

N/ A

ur

stereotyped and

en -

Problem

aggressive/destructiv

adults

s

e behaviours in the

Inventor

intellectually

y

disabled

40

ACCEPTED MANUSCRIPT (BPI01) Assess the nature,

16

4

d Overt

prevalence and

(<15

Aggress

severity of

minute

ion

aggression in

s)

Scale

psychiatric

(MOAS

populations.

Not

Closed

specified

specifi

ve

of ADHD, ODD,

(5-10

Behavio

and CD in children

minute

ur

and adolescents.

s)

6 months

RI

4

Disorder Rating

Not

0

specifi ed

PT E

D

Scale Parent assessment of

90

Vari

Weekly to

n,

ADHD, ODD and

items

ed

life-time

Nolan,

aggression

(10

and

symptoms

AC

CE

Swanso

Scale

Closed

SC

45

NU

Identify symptoms

MA

Disrupti

Rating

0

ed

)

Pelham

Not

PT

Modifie

Closed

Not

0

specifi ed

minute s)

(SNAPIV)

41

ACCEPTED MANUSCRIPT

AC

CE

PT E

D

MA

NU

SC

RI

PT

Graphical abstract

42

ACCEPTED MANUSCRIPT Highlights Instruments used to measure violent and aggressive behaviors in youth are lacking These tools are essential for conducting randomised controlled trials (RCTs) in this population We reviewed the instruments used in RCTs in violent and aggressive youth Most instruments aren’t specifically focussed on violence and aggression

AC

CE

PT E

D

MA

NU

SC

RI

PT

The CAS is psychometrically sound and measures aggressive and violent behaviors

43