The Diagnostic Interview of Children and Adolescents for Parents of Preschool and Young Children: Psychometric Properties in the general Population

Psychiatry Research 190 (2011) 137–144

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Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

The Diagnostic Interview of Children and Adolescents for Parents of Preschool and Young Children: Psychometric Properties in the general Population Lourdes Ezpeleta a,⁎, Núria de la Osa a, Roser Granero b, Josep Maria Domènech b, Wendy Reich c a

Unitat d'Epidemiologia i de Diagnòstic en Psicopatologia del Desenvolupament. Departament de Psicologia Clínica i de la Salut. Universitat Autònoma de Barcelona, Bellaterra (Barcelona), Spain Unitat d'Epidemiologia i de Diagnòstic en Psicopatologia del Desenvolupament. Departament de Psicobiologia i Metodologia de les Ciències del Comportament. Universitat Autònoma de Barcelona, Bellaterra (Barcelona), Spain c Division of Child Psychiatry, School of Medicine, Washington University, St. Louis, MO, USA b

a r t i c l e

i n f o

Article history: Received 30 June 2010 Received in revised form 20 April 2011 Accepted 27 April 2011 Keywords: Diagnostic interview Diagnostic Interview for Children and Adolescent Preschool Psychopathology Test–retest

a b s t r a c t There is a need for reliable and well-validated diagnostic measures for studying psychopathology in preschool and young children. The goal is to study the psychometric properties of the Diagnostic Interview for Children and Adolescents for Parents of Preschool and Young Children (DICA-PPYC) in the general population. A sample of 852 Spanish school children, aged 3 to 7 years, were randomly selected and screened for a double phase design. A total of 251 families were interviewed with the DICA-PPYC and 244 participated in a test– retest design. Different measures of psychopathology and functional impairment were also administered. Test–retest agreement with a mean interval of 8.8 days ranged from excellent to slight (kappa from 1 to 0.39) for DSM-IV-TR and from good to fair (kappa from 0.77 to 0.49) for Research Diagnostic Criteria-Preschool Age diagnoses. Attenuation between test and retest was not significant for the prevalence of diagnoses, although it was significant for the number of externalising and total symptoms in the interview. The diagnoses converged moderately with the CBCL and Dominic scores. The presence of diagnoses in the DICA-PPYC significantly differentiated preschoolers and young children who had used mental health services, were more impaired, and presented more severe psychopathology measured by dimensional scales. The DICA-PPYC is a reliable and valid semi-structured interview schedule for preschool and young children, and can serve to advance the knowledge and mental health care of this population. © 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction A standard procedure for deriving categorical diagnoses is using structured diagnostic interviews. Angold et al. (2007) have indicated that a great deal of work has been done with diagnostic interviews for children and adolescents. They stress that the current need is to extend the range of structured assessments to include younger ages. Some of the most developed diagnostic interviews have extensive preschool versions. They consist of modifications of the original

Abbreviations: ADHD, attention deficit hyperactivity disorder; ADHD-HI, attention deficit hyperactivity disorder—hyperactive–impulsive type; CBCL, Child Behavior Checklist; CD, conduct disorder; CGAS, Children's Global Assessment Scale; DICAPPYC, Diagnostic Interview for Children and Adolescents for Parents of Preschool and Young Children; GAD, generalised anxiety disorder; MD, mean difference; MDD, major depression; ODD, oppositional defiant disorders; OR, odds ratio; PAPA, Preschool Age Psychiatric Assessment; PD, proportion difference; RDC-PA, Research Diagnostic Criteria for Infants and Preschool Children; SAD, separation anxiety disorder; SES, socioeconomic status. ⁎ Corresponding author at: Departament de Psicologia Clínica i de la Salut. Edifici B, Universitat Autònoma de Barcelona, 08193 Bellaterra (Barcelona), Spain. Tel.: + 34 93 581 2883; fax: + 34 93 274 5776. E-mail address: [email protected] (L. Ezpeleta). 0165-1781/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2011.04.034

interviews that have been adapted for young children in wording and with appropriate questions to determine childhood manifestations of the psychiatric disorders. In some cases the introduction of new diagnoses is deemed essential as is the modification of the algorithms. The Preschool Age Psychiatric Assessment (PAPA) (Egger and Angold, 2004) represents an excellent effort for assessing psychopathology in this age group. The PAPA is an interviewer-based schedule for children from 2 to 5 years old based on the Child and Adolescent Psychiatric Assessment (Angold and Costello, 2000). A test–retest study with 307 parents of 2- to 5- year-old children receiving paediatric primary care showed slight to good agreement (Byrt, 1996) for diagnoses and good reliability for the assessment of impairment. These levels are similar to those obtained in the most accepted interviews for children and adults (Egger, et al., 2006). Birmaher et al. (2009), using the K-SADS-PL (Kaufman et al., 1997) in a sample of 204 children of bipolar parents and community controls, aged 2 to 5 years, showed high inter-rater reliability based on seven audiotaped cases, good convergent and discriminant validity with dimensional measures, good predictive intake diagnosis at 2- year follow-up, and agreement with PAPA diagnoses based on 14 subjects with a limited range of symptoms. The DISC-IV-YC (Lucas et al., 1998), a structured interview, was developmentally modified to address age-appropriate

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manifestation of symptoms and the life experiences of preschoolers. Luby et al. (2002), using this schedule, validated the DSM-IV major depression criteria modified for preschool children. The Diagnostic Infant and Preschool Assessment (Scheeringa and Haslett, 2010) for 1to 6- year-old children, showed slight to good test–retest reliability in seven of the most common DSM-IV disorders in a sample of 50 outpatients. Recently, there has been important growth in the study of psychopathology in preschool and young children (Egger et al., 2006; Egger and Angold, 2006; Angold and Egger, 2007; Lavigne et al., 2009). A key issue in this field has been whether or not categorical definitions of the diagnostic systems could be applied reliably to this age group. Some researchers suggest that standard DSM-IV criteria, when applied to preschoolers and young children, are not always sufficiently sensitive to ascertain symptomatic children and propose developmentally appropriate criteria for determining psychopathology in young children (Luby et al., 2002, 2003; Wakschlag et al., 2010). This is the case of the proposal of the Research Diagnostic Criteria— Preschool Age (RDC-PA) (Task Force on Research Diagnostic Criteria: Infancy Preschool, 2003) that was designed to “fill a gap in the knowledge of how to reliably diagnose psychiatric disorders in children from zero through five years of age” (p. 1). Further work on the development of these instruments is essential for the advancement of the field. There is a need for reliable and wellvalidated structured and semi-structured diagnostic measures with a different range of disorders, ages, degree of structure, or period assessed, for understanding and studying preschool psychopathology in different populations. The goal of this study is to assess the feasibility of the Diagnostic Interview for Children and Adolescents for Parents of Preschool and Young Children (DICA-PPYC) through a test– retest design and the analysis of the convergence of the results with other criteria. Even considering available schedules, there is a rationale for the development of a new interview such as the DICAPPYC. In comparison with other interviews, disorders are assessed in a lifetime timeframe. The DICA-PPYC extends the range to incorporate 3- to 7- year-olds. Regarding the degree of structure, it is an intermediate schedule situated between the most classical semistructured interviews (PAPA, K-SADS-PL) and the structured ones (DISC-IV-YC). It is syndrome organised and it covers a wide range of disorders. Also, the only schedule available in Spanish (American Spanish) is the DISC-IV-YC, which is a structured schedule; there is no structured or semi-structured diagnostic interview adapted for the Spanish preschool population. Finally, availability of this instrument would provide a useful comparison for DICA studies of older children, and the possibility of progression from preschool to older child assessments in follow-up studies for clinicians and researchers using this instrument. This study represents the first research to be done on preschool and young child disorders with a semi-structured diagnostic interview in a general population of Spanish children. 2. Method 2.1. Participants and design The initial sample consisted of 852 preschool children (ages 3 to 5) and first and second graders (ages 6 to 7) from the general school population (private and public) in Barcelona (Spain). Participants were stratified by socioeconomic status (SES) (Hollingshead, 1975) (Fig. 1). Five-hundred fifteen families (60.4%) agreed to participate in the first phase of the screening. There were no sex (p=0.73) or age (p=0.06) differences between those who agreed to participate and those who did not. The Child Behavior Checklist (CBCL; Achenbach and Rescorla, 2000, 2001) was used as a screening instrument to ensure inclusion of children with possible psychological problems. Two groups were defined: the screen positive, consisting of all the children with CBCL T-scores ≥65 on internalising, externalising or total, and the screen negative, which consisted of a randomly selected 40% of the children with CBCL T-scores b65 on the same scales. Thirty-two cases (6.2%) refused participation in the second phase of the study. These cases did not differ in sex (p= 0.64) from those who agreed to participate. However, children who accepted were younger (mean age 5.23 vs. 5.84; p=0.02). The final sample included 251 children between 3 and 7 years of age (mean age =5.2; S.D.=1.4), 135 (53.8%) were boys, 108 (43.1%) attended public schools and 143

Fig. 1. Design of the study.

(56.9%) private schools. Ethnic background distribution was: 95.2% Caucasian, 2.4% Hispanic–American, and 2.4% from other groups. The children mostly lived with both biological parents (96.8%); 92.7% of the fathers and 77.5% of the mothers were employed. Eighty-one (32.3%) had used services for any mental health problem of the child ever. The screen positive was formed by 33 children (22–66.7%—boys, mean CBCL scores: total 67.4, internalising 70.3, externalising 64.9). The screen negative group was formed by 218 children (113–51.8%—boys, mean CBCL scores: total 45.5, internalising 47.1, externalising 46.1). Mothers answered the CBCL in 28% of the cases, fathers in 2.2% and both parents together in 69.8%. Children showing intellectual disability, pervasive developmental disorders or difficulties with Spanish or Catalan were excluded (four children). Seven families (2.8%) abandoned the study between the test and the retest.

2.2. Measures 2.2.1. Diagnostic Interview for Children and Adolescents for Parents of Preschool and Young Children (DICA-PPYC) The DICA-PPYC (Reich and Ezpeleta, 2009) is a semi-structured interview for parents of children between 3 and 7 years old based on the Diagnostic Interview for Children and Adolescents-IV (DICA-IV) (Reich et al., 1997; Reich and Todd, 2002b), the Missouri Assessment for Genetics Interview for Children (Reich, 2000) and the Diagnostic Interview for Children and Adolescents for Parents of Young Children (Reich et al., 2001). The original interview has been described in Reich (2000). It is a computerised instrument that covers common diagnostic categories following DSM-IV-

L. Ezpeleta et al. / Psychiatry Research 190 (2011) 137–144 TR definitions (American Psychiatric Association, 2000) (29 diagnoses) and Research Diagnostic Criteria—Preschool Age (RDC-PA) (Task Force on Research Diagnostic Criteria: Infancy Preschool, 2003) (12 diagnoses). Table 2 shows the diagnoses included in the interview. The diagnoses that were added to the preschool and young children version include: feeding and eating disorders of infancy or early childhood (pica and feeding disorders of infancy or early childhood), sleep disorders (insomnia, hypersomnia, nightmare disorder, sleep terror disorder, sleepwalking disorder), selective mutism, reactive attachment disorder of infancy or early childhood, stereotypic movement disorder, and stuttering. Some other areas are also explored though it is not possible to derive a diagnosis (i.e. communication disorder and somatisation). Questions for all diagnoses were written to be appropriate for young children. Questions covering RDC-PA experimental symptoms were included. After the assessment of the symptoms of each disorder, the following information was obtained: clustering of the symptoms, age at onset and age when the symptoms finished, duration criteria, whether professional help was sought, impairment at home, at school, and with friends, distress and family burden. We used one of the two most frequent designs to adapt psychological instruments as proposed by Brislin (1986) and Triandis (1996): a direct translation submitted to the independent judgment of several translators. The translators were not only fluent in both English and Spanish, but experts in the construct being assessed as well as the underlying psychometric concepts. The interview was first translated by two of the authors (L.E. and N.O.) from English into Spanish and Catalan. Then, a committee formed by one child psychiatrist and two clinical child psychologists independently reviewed the translations and agreed on a final version. Pilot applications permitted the verification of the appropriateness of the translations and this final version was compared again against the original. Diagnoses were generated through computerised algorithms written in SPSS, following, as far as possible, the DSM-IV-TR algorithms developed for the DICA for older children or the RDC-PA definitions. An example of this adaptation is the treatment of conduct disorder (CD). The symptoms of breaks into properties, stays out at night, runs away, and truant were not included in the algorithm. Subthreshold conditions were defined as cases that did not meet threshold criteria but indicated impairment. Subclinical included cases where the threshold of symptoms was met but impairment was not present. Composite diagnoses and counts of the number of disorders or symptoms were developed. The number of disorders present (DSM or RDC-PA) was the sum among those evaluated in the interview. The number of externalising symptoms included attention deficit/hyperactivity disorder (ADHD), oppositional defiant (ODD) and CD symptoms. The number of internalising symptoms included symptoms of major depression, separation anxiety (SAD), generalised anxiety (GAD), specific phobia, social phobia, and obsessive–compulsive. The total number of symptoms was calculated summing internalising and externalising symptoms. Disorders were assessed over the lifetime (past and present diagnosis can be derived). A modification of the specifications manual (Reich and Todd, 2002a) explains the symptoms and the disorders and how to code them. Mothers were the reporters of the interview in 74.5% of the cases, fathers in 5.2% and both parents together completed a single interview in 20.3%. In three cases the reporter in the test was different from the reporter in the retest.

2.2.2. Child Behaviour Checklists The Child Behaviour Checklist for pre-school (CBCL 1½–5) (Achenbach and Rescorla, 2000) and for school-age children (CBCL 6–18) (Achenbach and Rescorla, 2001) measure psychopathology dimensionally. They contain 100 and 113 questions respectively, with three response options indicating various behavioural and emotional problems in children. Since the number of items included in the empirical syndrome scales was not the same for the pre-school and school-age versions (consequently, neither was the range of total direct scores), T-scores were analysed.

2.2.3. Dominic Interactive The Dominic Interactive (Valla et al., 2000) is a computerised cartoon questionnaire that includes 80 situations presenting DSM-IV behavioural and emotional symptoms. It was used to assess a child's self-reported psychopathology from ages 6 to 7. Raw scores in each scale were analysed. Alpha internal consistency in the sample ranged from moderate to very good: specific phobia 0.59, separation anxiety 0.71, generalised anxiety 0.74, depression/dysthymia 0.74, ODD 0.68, conduct disorder 0.80, ADHD 0.87, internalising 0.88, externalising 0.91 and 0.94 total.

2.2.4. The Children's Global Assessment Scale (CGAS) The CGAS (Shaffer et al., 1983; Ezpeleta et al., 1999) is a global measure of functional impairment. Scale scores range from 1 (maximum impairment) to 100 (normal functioning). Scores higher than 70 indicate normal adaptation. The lowest lifetime CGAS score was used as a criterion for studying validity.

2.2.5. Brief Impairment Scale (BIS) The BIS (Bird et al., 2005) is a global measure of impairment that does not link impairment to specific disorders. It contains 23 parent-reported items that evaluate a child's impairment for interpersonal relations, at school, and for self-fulfilment over the last year. Total score was used. Cronbach's alpha internal consistency in the sample was 0.75 for the total score.

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2.3. Procedure The project was approved by the ethics review committee of author's institution. After a complete description of the study was given to the directors of the schools and to the parents, written consent was obtained from the parents. In Spain preschool education is mandatory from age 3. All the children from P3 (3-year-olds) to second grade of the participating schools were invited to answer the CBCL. Families who agreed to participate and who fulfilled the screening criteria were contacted by telephone and were interviewed at the school on two occasions by different trained interviewers (test and retest) 1 week apart. Interviewers were blind to the screening group and to the results of the test interview. Interviewers changed in the test and retest. All the interviews were audio-recorded and supervised. Weekly meetings were scheduled to monitor the cases and the team members discussed the cases and difficulties in coding the interviews after both interviews (test and retest) were completed. After each interview, interviewers rated the CGAS and the parents completed the BIS. The Dominic questionnaire was answered by 88 6- to 7- year-old children individually. 2.3.1. Training for the DICA-PPYC The characteristics of the symptoms, methods of identifying these characteristics and how to code the symptoms were taught during the training. An intensive training period that lasted 1 week included an overview of developmental psychology and psychopathology of preschool children, as well as interviewing skills. Then, a longer training period was composed of the following four phases: 1) study of the interview: information about the purpose, structure, content, relationships between the questions and DSM-IVTR/RDC-PA criteria, use of the software, codes, and algorithms; 2) practise interviews and role playing of simulated interviews; 3) listening and coding of audio-recorded real interviews; and 4) observation and coding of live interviews. The criterion for being ready for the field was to obtain a mean agreement with an expert kappa ≥0.80 for all the questions in at least five interviews. The team of interviewers consisted of two Ph. D. clinical psychologists (24 and 10 test; 13 and 19 retest interviews), three psychologists with masters' degrees (29, 54, and 55 test; 29, 54, and 63 retest interviews) and five psychology students (19, 18, 13, 11, and 18 test; 23, 13, 17, 7, and six retest interviews). 2.3.2. Statistical analysis Data were analysed with Stata/IC 11.0 for Windows. Confidence intervals of the prevalences were estimated with Wilson's method (Newcombe, 1998; Altman et al., 2000). All the analyses were weighted assigning sampling weights inversely proportional to the probability of participant selection (Fig. 1). Robust estimations were carried out to produce unbiased parameter estimates and appropriate standard error generalisable to the original population. The test–retest diagnostic agreement was calculated with Cohen's kappa for categorical variables (the presence of DSM-IV-TR and RDC-PA diagnoses) and the intraclass-correlation coefficient for quantitative measures (the number of symptoms and disorders). The presence of attenuation, that is, the reduction of symptoms reported in subsequent assessments, was analysed comparing the prevalence of disorders in the test and retest with proportion differences, and the number of total symptoms and disorders with mean differences. Convergence between DICA-PPYC indicators and other psychopathological measures (CBCL, Dominic scores and impairment) was studied through correlation coefficients (Pearson's, Spearman's Rho and point-biserial). It was considered that a value was large when |R| ≥ 0.30. To determine if children with identified diagnoses in the DICA-PPYC had used more services, had higher scores on the total CBCL and Dominic scores, and higher impairment than children without a diagnosis, proportions and mean scores were analysed through logistic and linear regressions adjusted by other comorbidities different to those included in each model.

3. Results 3.1. Test–retest interval The test and retest intervals ranged from 4 to 40 days, with a mean of 8.83 days (S.D. = 4.8), and an inter-quartile range comprised between 7 and 8 days. 56.6% of the retests (138 assessments) were done between days; 7 and 8, 40.5% (99 cases) between days 8 and 15, and only the 2.9% remaining (seven cases) in over 15 days. 3.2. Duration of the interviews The test interviews had a mean length of 50.4 min (S.D. = 17.8), while the retest interviews lasted 42.8 (S.D. = 17.0). The retest

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interviews were significantly shorter than the test interviews (p b 0.001). There were no differences in the length of the interviews between boys and girls, nor between preschool (ages 3, 4, 5) and school (ages 6, 7) children (Table 1). However, the interviews of children with psychopathology, with impairment, and with more diagnoses were significantly longer than those without psychopathology, without impairment and with no or one diagnosis.

3.3. Test–retest diagnostic agreement Table 2 presents the prevalence of DSM-IV-TR and RDC-PA in the test and retest interviews as well as the number of cases with a diagnosis in the test “and” retest. Prevalence of any DSM-IV-TR diagnosis was 36.3%. The most prevalent DSM-IV-TR disorders were enuresis, specific phobia, ODD and ADHD; the most frequent for RDC-PA were ODD and ADHD. For DSM-IV-TR diagnoses kappa concordance was excellent for encopresis, tic disorders and Tourette; very good for ADHD, elimination disorders, enuresis, and transient tic; good for any diagnosis, disruptive behaviour disorders, ODD, major depression, anxiety disorders, SAD, specific and social phobia, obsessive–compulsive disorder, stereotypic movement, insomnia, and sleepwalking; it was fair for GAD, feeding and eating disorders, sleep disorders and sleep terror; and slight for stuttering (Table 2). For RDC-PA diagnoses kappa concordance was good for all the disorders except CD and sleep onset and night waking protodyssomnias, which were fair. Agreement was calculated based on very few cases for major depression, GAD, obsessive–compulsive disorder, Tourette, chronic tics, feeding disorders, nightmare, and sleepwalking. Mania/hypomania, dysthymic disorder, posttraumatic stress disorder, pica, hypersomnia, selective mutism, reactive attachment disorder, and RDC-PA feeding disorders had no cases and were excluded from these analyses. Agreement was poor for subthreshold definition and it was fair for subclinical. When independent estimations were calculated by sex (boys and girls) and age (3 to 5 vs. 6 to 7), the test–retest agreement became poor for 3 to 5 year-old girls DSM-IV-TR and RDC-PA ADHD; for 6 to 7 year-old girls insomnia; and for 6 to 7 year-old boys social phobia, stuttering and RDC-PA night waking protodyssomnia. Table 2 shows whether the drop in the retest prevalences was significant and indicative of attenuation between the test and the retest interviews. The changes in the prevalences of the test and the retest were calculated through proportion differences (PD). If the difference between the test and retest is significant, it means there is a change, which is indicative of attenuation when proportion difference is significant and higher than 0. Most of the values were greater than 0, indicating attenuation, namely, the proportion of cases having a diagnosis was greater at the test than at the retest. Only for any RDCPA diagnosis were there significant proportion differences, implying a significant decrease in its prevalence (PD = 3.69%; 95% CI: 0.26% to 7.3%).

Table 1 Length in minutes of the interviews (mean and standard deviation). Test Boys Girls Ages 3, 4, 5 Ages 6, 7 No diagnosis With diagnosis No impairment With impairment 0–1 diagnosis 2 or more diagnoses

50.4 50.5 50.8 50.0 48.2 53.9 48.1 60.6 48.9 58.1

p (17.5) (18.3) (16.8) (19.2) (17.2) (18.2) (17.0) (18.0) (17.7) (16.3)

Retest 0.958 0.747 0.016

b0.001 0.003

43.9 (18.4) 41.6 (15.2) 44.2 (17.9) 41.0 (15.6) 40.2 (16.1) 46.8 (17.5) 40.8 (16.3) 50.4 (17.5) 41.6 (16.9) 50.0 (15.5)

p 0.301 0.164 0.003

Table 3 shows the results of the agreement between the test and the retest for symptom scale scores. The agreement ranged between good and very good (0.72 and 0.89). The number of externalising symptoms and the total number of symptoms in the interview diminished significantly from the test to the retest. 3.4. Convergent validity Associations of the DICA-PPYC diagnoses and the CBCL scales were between low and moderate (Table 4). Diagnoses significantly associated with the scales theoretically most related with them. The exception was DSM-IV-TR GAD and major depression. ADHD and attention problems obtained the highest correlations. In addition, the number of disorders and symptoms in the DICA-PPYC (internalising, externalising and total) significantly correlated with the total CBCL scores, with r-values ranging from 0.26 to 0.60 (data not shown). The lowest correlation was found for the total number of DSMIV disorders and the total number of internalising symptoms with CBCL 1½–5 externalising score (r = 0.16, p = 0.07 and r = 0.14, p = 0.13, respectively). Few point-biserial correlations between the DICA-PPYC diagnoses and the correspondent Dominic Interactive scales reached significance and were higher than 0.30. For DSM-IV-TR diagnoses the significant associations were: a) disruptive disorders diagnoses with externalising scale (rpb = 0. 34, p = 0.008), depression scale (rpb = 0.31, p = 0.007) and behavioural problems scale (rpb = 0.32, p = 0.050); and b) ADHD diagnosis with externalising scale (rpb = 0.30, p = 0.03) and total scale (rpb = 0.30, p = 0.01). For RCD = –PA diagnoses the significant associations were: a) ADHD diagnosis and externalising scale (rpb = 0. 30, p = 0.04), total scale (rpb = 0.30, p = 0.01) and depression scale (rpb = 0.30, p = 0.01); b) disruptive disorders diagnoses with depression scale (rpb = 0.31, p = 0.007), behavioural problems scale (rpb = 0.32, p = 0.050) and externalising scale (rpb = 0.34, p = 0.005); and c) any diagnosis and behavioural problems score (rpb = 0.32, p = 0.008). The number of DSM-IV disorders, externalising and total symptoms were significantly correlated (p b 0.05) with Dominic internalising, externalising and total scores (r-coefficients ranging between 0.22 and 0.35). The number of DSM-IV internalising symptoms did not correlate significantly with externalising, internalising or Dominic total scores. Table 5 shows the association of DSM-IV-TR or RDC-PA diagnoses and use of services, functional impairment and total scores in dimensional scales. The presence of any diagnosis significantly differentiated preschoolers who had used services for mental health problems, had higher impairment and higher total symptoms as measured in dimensional scales (except Dominic for DSM-IV-TR diagnosis). ADHD diagnoses significantly differentiated preschoolers that had used services, with higher impairment and higher total problems scores. DSM-IV-TR ODD significantly differentiated preschoolers who had used services, had higher impairment and higher CBCL total symptoms; RDC ODD differentiated those with higher impairment and with higher scores on total CBCL. RDC CD did not converge significantly with any criteria. Separation anxiety significantly differentiated preschoolers with higher impairment and higher total CBCL scores. Generalised anxiety converged with higher impairment, CBCL and Dominic scores. Specific phobia diagnosis was associated with higher CGAS impairment and higher CBCL total score, and social phobia diagnosis with higher CGAS impairment, CBCL and Dominic scores. 4. Discussion

b0.001 0.007

The DICA-PPYC is a reliable and valid semi-structured interview schedule for the assessment of preschoolers' psychopathology: it is a stable measure that is able to discriminate between clinically significant

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Table 2 Prevalence of diagnoses, test–retest agreement and attenuation. Total sample (N = 244)

Kappa by age–sex

Prevalence (%) and 95% CI for test (unweighted N) Retest

Test and ret.

PD (%)

kappa

Boys 3–4–5 (N = 68)

36.3 9.5 5.1 0.8 3.3 1.2 5.6 0.0

30.6 ÷ 42.5 6.4 ÷ 13.8 3.0 ÷ 8.7 0.2 ÷ 2.7 1.6 ÷ 6.3 0.4 ÷ 3.6 3.4 ÷ 9.3 0.0 ÷ 1.6

(97) (29) (17) (2) (10) (5) (16) (0)

36.6 (97) 7.5 (25) 4.5 (16) 0 (0) 2.5 (9) 2.0 (7) 4.7 (15) 0.6 (2)

29.4 (80) 6.6 (22) 4.1 (14) 0 (0) 2.0 (7) 1.2 (5) 3.3 (11) 0 (0)

− 0.41 2.05 0.82 – 0.82 − 0.82 0.82 –

0.69 0.76 0.83 – 0.71 0.75 0.65 –

0.67 0.79 0.79 – – – 0.74 _

0.77 0.30 0.01 – – – 0.38 –

0.80 0.94 1.0 – 1.0 0.46 0.78 –

0.51 0.65 0.65 – – – 0.66 –

0.6 10.0 2.1 0.9 6.7 2.8 0.6 12.2 11.1 1.3 3.7 0.4 0 3.3 9.4 0.2 6.5 4.8 0 0.9 2.2 1.1 2.2 24.6 16.0 6.0 0.8 4.1 1.2 6.7 2.6 0.6 2.1 3.0 2.0

0.2 ÷ 2.7 6.8 ÷ 14.4 0.9 ÷ 4.8 0.3 ÷ 3.0 4.2 ÷ 10.5 1.4 ÷ 5.7 0.2 ÷ 2.7 8.7 ÷ 16.9 7.8 ÷ 15.7 0.5 ÷ 3.6 2.0 ÷ 6.9 0.1 ÷ 2.3 0.0 ÷ 1.6 1.7 ÷ 6.3 6.3 ÷ 13.7 0.0 ÷ 1.9 4.1 ÷ 10.4 2.7 ÷ 8.2 0.0 ÷ 1.6 0.3 ÷ 3.0 1.0 ÷ 4.9 0.3 ÷ 3.3 1.0 ÷ 4.9 19.6 ÷ 30.3 12.0 ÷ 21.1 3.7 ÷ 9.7 0.2 ÷ 2.7 2.2 ÷ 7.4 0.4 ÷ 3.6 4.2 ÷ 10.6 1.2 ÷ 5.5 0.2 ÷ 2.7 0.9 ÷ 4.8 1.5 ÷ 6.0 0.8 ÷ 4.6

(2) (28) (7) (2) (20) (8) (2) (31) (28) (4) (9) (1) (0) (8) (25) (1) (17) (13) (0) (2) (5) (4) (5) (58) (46) (19) (2) (12) (5) (19) (7) (2) (7) (9) (5)

0.2 (1) 9.1 (26) 2.6 (8) 0.6 (2) 5.4 (17) 3.9 (10) 0.4 (1) 10.7 (28) 9.6 (25) 1.3 (4) 3.9 (10) 0.4 (1) 0.9 (3) 2.6 (6) 8.3 (22) 0.9 (3) 7.8 (21) 4.8 (14) 0.9 (2) 0.4 (1) 2.2 (5) 0.9 (2) 2.6 (7) 20.2 (47) 12.1 (37) 5.3 (18) 0 (0) 3.3 (11) 2.0 (7) 5.4 (17) 1.7 (5) 0.2 (1) 3.0 (9) 1.9 (7) 0.9 (3)

0.4 (1) 7.4 (21) 2.0 (6) 0.4 (1) 4.5 (14) 2.0 (6) 0.4 (1) 9.8 (26) 9.0 (23) 1.2 (4) 3.7 (9) 0.4 (1) 0 (0) 2.5 (6) 6.2 (17) 0.4 (1) 4.5 (12) 2.9 (9) 0 (0) 0.4 (1) 1.2 (3) 0.4 (1) 0.4 (1) 12.7 (30) 10.7 (32) 4.5 (15) 0 (0) 2.5 (8) 1.2 (5) 3.7 (12) 1.2 (4) 0.4 (1) 2.0 (6) 1.2 (5) 0.8 (2)

0.41 0.82 − 0.41 0.00 1.23 − 0.82 0.41 1.23 1.23 0.00 − 0.41 0.00 – 0.82 0.82 0.82 − 1.63 0.00 – 0.41 0.00 0.41 − 0.41 4.51 3.69⁎ 0.82 – 0.82 − 0.82 1.23 0.82 0.41 − 0.82 0.82 0.82

0.67 0.76 0.76 0.50 0.74 0.61 0.67 0.86 0.85 1.0 0.95 1.0 – 0.85 0.69 0.50 0.58 0.62 – 0.67 0.59 0.39 0.16 0.45 0.71 0.77 – 0.65 0.75 0.60 0.59 0.67 0.71 0.49 0.49

– 0.64 0.49 – 0.79 0.79 – 0.84 0.82 1.0 0.90 – – 0.88 0.58 – 0.41 0.55 – – – – 0.20 0.46 0.58 0.55 – – – 0.64 0.49 – 0.49 0.66 1.0

– 0.75 1.0 – 0.71 0.49 – 1.0 1.0 – – – – – 0.78 – 0.88 0.85 – – 1.0 1.0 – 0.28 0.31 0.01 – – – 0.25 – – 1.0 0.49 –

0.66 0.82 0.85 0.66 0.73 0.02 1.0 0.80 0.79 1.0 1.0 1.0 – 0.66 0.90 1.0 0.57 0.64 – – – 0.02 – 0.66 0.87 0.91 – 1.0 0.46 0.81 0.79 0.66 0.73 0.55 0.02

– 0.66 1.0 – 0.63 0.79 – 0.79 0.79 – 1.0 – – 1.0 0.29 – 0.46 0.02 – 1.0 0.37 – 0.02 0.49 0.88 0.85 – – – 0.66 1.0 – 1.0 – –

Test; 95% CI Any DSM-IV diagnosis Disruptive behaviour disorders ADHD Inattentive‡ Hyperactive-impulsive Combined ODD CD Mood disorders Major depression‡ Anxiety disorders SAD GAD ‡ Specific phobia Social phobia Obsessive–compulsive dis.‡ Elimination disorders Enuresis Encopresis Tic disorders Tourette‡ Chronic motor or vocal tic‡ Transient tic disorder Stereotypic movement dis. Feeding and eating disorders‡ Sleep disorders Insomnia Nightmare disorder‡ Sleepwalking disorder‡ Sleep terror disorder Stuttering Subthreshold Subclinical Any RDC-PA diagnosis ADHD Inattentive‡ Hyperactive–impulsive Combined ODD CD Major depressive disorder‡ SAD Sleep onset protodyssomnia Night waking protodyssomnia

Attenuattion

Agreement

Girls 3–4–5 (N = 70)

Boys 6–7 (N = 61)

Girls 6–7 (N = 45)

PD: proportion difference. Empty cell: not-estimable coefficient due to the lack of prevalent cases; ADHD: attention deficit hyperactivity disorder; CD: conduct disorder; GAD: generalised anxiety disorder; MDD: major depression; ODD: oppositional defiant disorder; SAD: separation anxiety disorder. ‡ Indexes calculated with a small number of cases. ⁎ Significant coefficient.

groups. The results of this study on this instrument contribute to the scarce literature currently available and show that it is possible to use structured diagnostic interviews in this age range.

In the process of the development of an instrument, the test–retest is the most relevant and rigorous procedure, as it indicates the stability of the measure despite all the possible changes that could have

Table 3 Mean of quantitative indicators of DICA-PPYC and impairment in test and retest, agreement and attenuation. Mean (S.D.) (N = 244)

Test

Number DSM-IV disorders Number externalising symptoms Number internalising symptoms Number total symptoms Number RDC-PA disorders Number RDC-PA symptoms CGAS BIS: total score

0.59 2.82 1.60 4.43 0.23 4.11 77.3 8.09

(1.0) (4.3) (2.3) (5.3) (0.6) (5.3) (10.6) (6.0)

SD: standard deviation. ICC: intraclass correlation coefficient. MD: mean difference. ⁎ Significant coefficient.

Agreement

Attenuation

Retest

ICC

MD

0.56 2.47 1.51 3.98 0.18 3.62 77.0 6.75

0.84 0.89 0.77 0.88 0.72 0.89 0.86 0.73

0.03 0.36⁎ 0.09 0.45⁎

(0.9) (4.2) (2.4) (5.3) (0.6) (5.2) (10.1) (5.5)

0.05 0.48⁎ 0.30 1.34⁎

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L. Ezpeleta et al. / Psychiatry Research 190 (2011) 137–144

Table 4 Association between DICA-PPYC and CBCL scales. DICA-PPYC

CBCL

Diagnoses

Specific scale

Internalising CBCL 1

1/2

–5

CBCL

CBCL

6–18

1/2

DSM-IV-TR Any diagnosis Disruptive behaviour disorders ADHD ODD Major depression Anxiety disorders SAD GAD Specific phobia Social phobia Obsessive-compulsive disorder Insomnia Sleep terror disorder

Attention problems Aggressive behaviour Anxious-depressed

0.28⁎ 0.36⁎ —

0.49⁎ 0.44⁎ 0.06

Anxious-depressed Anxious-depressed Anxious-depressed Anxious-depressed Anxious-depressed Sleep problems Sleep problems

0.29⁎ 0.02 0.28⁎ 0.24⁎ 0.22⁎ 0.25⁎ 0.30⁎

0.28⁎ 0.15 0.27⁎

RDC Disruptive behaviour disorders ADHD ODD CD Major depressive disorder SAD Sleep onset protodyssomnia Night waking protodyssomnia

Attention problems Aggressive behaviour Rule breaking Anxious-depressed Anxious-depressed Sleep problems Sleep problems

0.36⁎ 0.44⁎

0.49⁎ 0.44⁎ 0.26⁎

— 0.29⁎ 0.33⁎ 0.28⁎

0.06 0.28⁎

1

–5

0.17⁎ 0.31⁎ 0.25⁎ 0.24⁎

CBCL

6–18

1/2

1

0.28⁎ 0.23⁎ 0.25⁎ 0.05 0.04 0.35⁎ 0.20 0.13 0.34⁎

— 0.33⁎ 0.38⁎ 0.04 0.30⁎ 0.32⁎ 0.26⁎

-0.01 0.15

Externalising CBCL

0.01 0.14

0.03 0.13 0.19 -0.08

0.29⁎ 0.20⁎ 0.26⁎ 0.04 — 0.38⁎ 0.08 0.09

0.31⁎ 0.25⁎ 0.05 0.04 0.04 0.20 0.22⁎ -0.06

–5

Total CBCL

CBCL

CBCL

6–18

1/2

6–18

1

–5

0.05 0.43⁎ 0.27⁎ 0.37⁎

0.43⁎ 0.46⁎ 0.31⁎ 0.42⁎

0.13 0.39⁎ 0.28⁎ 0.32⁎

0.44⁎ 0.42⁎ 0.35⁎ 0.26⁎

— 0.06 0.24⁎ 0.02 0.08 0.09 0.14 -0.05 0.04

-0.04 0.31⁎ 0.16 0.07 0.30⁎

— 0.23⁎ 0.30⁎ 0.06 0.21⁎ 0.22⁎ 0.23⁎

0.001 0.40⁎ 0.24⁎ 0.14 0.38⁎

0.40⁎ 0.28⁎ 0.42⁎ 0.24⁎

0.44⁎ 0.31⁎ 0.42⁎ 0.34⁎

0.04 0.07 0.22⁎ 0.04

— 0.24⁎ 0.01 -0.02

-0.04 0.16 0.16 -0.07

0.03 0.14

0.05 0.14 0.27⁎ -0.03

0.40⁎ 0.25⁎ 0.38⁎

0.46⁎ 0.35⁎ 0.26⁎

0.13 — 0.30⁎ 0.10 0.10

0.18 0.001 0.24⁎ 0.29⁎ -0.09

— Not-estimable coefficient due to the lack of prevalent cases. CBCL11/2–5 (N = 162); CBCL 6–18 (N = 89). Full table of correlations available from authors. ⁎ Significant point-biserial correlation.

happened in the time interval between the test and the retest (Robins, 1985). The levels of the test–retest stability were good and similar to those of the PAPA (Egger et al., 2006). For some disorders the agreement was based on very few cases and the results must be interpreted cautiously. It must be taken into consideration that the study was realised using a sample of young children from the general population where a high proportion of some disorders is not expected to be found. It is also worth noting the high stability of elimination, tic and disruptive disorder. The only non-significant concordance between the test and retest was in subthreshold definitions. Further work must be done on the stability of subthreshold definitions in preschoolers, given that in older ages, subthreshold status is relevant for treatment because they are cases with impairment (Angold et al., 1999), and this status is a

precursor of full syndrome disorder (Shankman et al., 2009). Because of its relevance as a key construct upon which to base the validity and clinical significance of psychiatric diagnoses in preschoolers (Egger et al., 2006), in this study, impairment was assessed with two different measures, combining methods and raters. The two measures obtained very good and good test–retest agreement and only the BIS presented a significant attenuation (a mean of 1.34 points less in the scores of the retest vs. test, which clinically is not very relevant). The diagnoses of the interview significantly converge with other measures that intend to assess similar constructs. We found, also, a good stability of impairment in preschool years. Although most of the prevalences tended to diminish at the retest (attenuation), the drop was only significant for RDC-PA any diagnosis. Because the RDC-PA criteria were developed specifically to adapt

Table 5 Convergent validity of DICA-PPYC DSM-IV-TR and RDC diagnoses.

Any diagnosis ADHD Oppositional defiant disorder Conduct disorder Separation anxiety disorder Generalised anxiety disorder Specific phobia Social phobia

Use of services (N = 251)

CGAS: total (N = 251)

OR§

95% CI

B‡

95% CI

B

DSM RDC DSM RDC DSM RDC DSM RDC DSM RDC DSM

2.52⁎ 5.21⁎ 6.65⁎ 7.92⁎ 5.76⁎ 1.66 — 3.60 1.60 1.96 —

1.44; 4.43 2.55; 10.6 1.87; 23.7 2.39; 26.2 1.64; 20.2 0.57; 4.88 — 0.38; 33.9 0.34; 7.45 0.33; 11.8 —

− 11.3⁎ − 17.3⁎ − 16.9⁎ − 16.2⁎ − 14.5⁎ − 7.74⁎

3.20⁎ 5.34⁎ 5.10⁎ 4.70⁎ 7.10⁎ 5.00⁎

1.54; 4.86 3.03; 7.66 1.56; 8.63 0.75; 8.64 2.34; 11.9 1.35; 8.65

— − 5.54 − 9.24 − 11.6⁎ − 14.6⁎

− 14.0; − 8.72 − 20.7; − 13.8 − 21.2; − 12.7 − 21.3; − 11.2 − 21.2; − 7.91 − 13.4; − 2.07 — − 13.4; 2.33 − 19.3; 0.82 − 22.8; − 0.33 − 25.6; − 3.46

— 4.49 5.45⁎ 6.05⁎ 7.23⁎

— − 2.41; 11.4 1.16; 9.74 1.31; 10.8 1.66; 12.8

DSM DSM

1.40 0.73

0.50; 3.91 0.14; 3.78

− 8.50⁎ − 13.4⁎

− 14.2; − 2.84 − 20.8; − 6.05

0.91 6.28

− 2.51; 4.33 − 0.85; 13.4

BIS: total (N = 251)

CBCL: total (N = 251) 95% CI

B

DOMINIC: total (N = 88) 95% CI

4.65⁎ 10.1⁎ 11.3⁎ 8.78⁎ 9.84⁎ 7.66⁎ — − 0.25 14.014.3⁎

2.43; 6.88 7.05; 13.2 7.79; 14.8 4.83; 12.7 5.98; 13.7 3.30; 12.0

8.17⁎

— − 6.53; 6.03 4.74; 23.3 6.71; 22.0 5.96; 10.4

8.14⁎ 6.41⁎

2.83; 13.4 1.50; 11.3

OR§: odds ratio of association between diagnosis and use of services adjusted by other comorbidity (logistic regression). B‡: mean difference in the scores of the groups with and without diagnosis estimated with linear regression adjusted by other comorbidity. — Not estimable due to the low prevalence of the disorder and/or the outcome. ⁎ Significant association.

B

95% CI

4.86 8.89⁎ 13.1⁎ 13.4⁎ 0.27 − 3.92 — − 0.90 6.53 7.33 22.3⁎ 6.75 7.09⁎

− 0.82; 10.5 1.88; 15.9 1.76; 24.5 1.87; 24.8 − 7.63; 8.17 − 12.6; 4.81 — − 13.1; 11.3 − 9.79; 22.8 − 12.4; 27.1 18.3; 26.3 − 0.76; 14.3 2.84; 11.3

L. Ezpeleta et al. / Psychiatry Research 190 (2011) 137–144

DSM-IV-TR definitions to a preschool population, we expected to obtain better indicators for analogous RDC-PA than DSM-IV-TR diagnoses, but this was not the case and the two were quite comparable, with DSM-IV-TR obtaining slightly higher kappas than RDC-PA (except in any diagnosis and ADHD-hyperactive/impulsive–ADHDHI). However, the RDC-PA seemed to detect more disruptive disorders than the DSM-IV-TR and the former identified two more cases of ADHD-HI, three of ODD and seven of CD in the test. Symptom scale scores obtained better reliability than categorical diagnoses, but they also showed more significant attenuation. The higher precision of continuous measures in comparison with categorical data could contribute to a higher differentiation between the test and retest. In clinical terms, this implies a mean of 0.36 externalising symptoms, or 0.45 (0.48 RDC-PA) total symptom less, in the retest than in the test, which is not very meaningful from a clinical viewpoint. In any case, both interviews and questionnaires have been shown to manifest attenuation and our results do not differ from those found before us. In this sense, the DICA-PPYC is behaving as expected. When agreement was estimated for individual age by sex subgroups, with few exceptions, there were no differences between test and retest. Our results, however, must be considered with caution because of the low number of prevalent cases in many disorders when the sample was split by sex and age. The prevalence found was high (36.3% for any diagnosis). It should be taken into consideration, however, that the DICA-PPYC included more disorders for calculating prevalences and a higher age range (from 3 to 7 years old) than those encompassed in other interviews. When disorders with a maturational component (marked fears, sleep, feeding disorders, stuttering) were excluded from any diagnosis, the prevalence dropped to 26.1%, and when elimination disorders were excluded, it fell to 17.1%. The interview converged moderately with other dimensional measures such as the CBCL and Dominic. Anxiety and mood were the categories that showed to have less association with the questionnaires. Similar results have been reported in studies with older children, which explained the moderate relationships through the different coverage of the instruments (Ferdinand, 2008), and in preschool children (Birmaher et al., 2009), where convergence between CBCL and mood was non-significant. The RDC-PA CD diagnosis did not converge with any of the studied variables. As it has been pointed out, much work must be done in current classification systems for preschool children (Egger and Emde, 2011), and we cannot contrast our results with those of other studies. Finally, diagnoses of the interview successfully differentiate children that used services for mental health problems and more severe indicators of psychopathology. The results of this study must be interpreted while considering some limitations. The lack of a “culture of research” in the general Spanish population contributes to the fact that participation in research is generally low. There was a considerable rejection percentage in the first phase of the study (39.6%). There were no sex or age differences between those who agreed to participate and those who did not, but fewer older children (6- to 7- year-olds) and fewer families from low socioeconomic levels participated in the study, and this could have introduced a bias. For some disorders there was a very low number of cases. More work is needed on the reliability and validity of those disorders with a very low number of cases. The sample was primarily Caucasian and results cannot be generalised to other racial/ethnic groups. We could not obtain information from the teachers, which might have contributed to validity issues. In comparison with other studies focusing on children ages 3 to 5, or with the other versions of DICA-MAGIC, which start at age 8, this interview covers the existing gap from ages 3 to 7. The study showed that the DICA is as reliable as any other measure currently used for child and adolescent psychiatric diagnosis, and that it performs well in relation to the external validators used.

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Acknowledgements and disclosures This work was supported by grant PSI2009-07542 from the Ministry of Science and Innovation (Spain). We want to thank the schools and the families that participated in the study. Competing interests: the authors have no competing interests.

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