Correspondence between statistically derived behavior problem syndromes and child psychiatric diagnoses in a community sample

The correspondence between Diagnostic and Statistical Manual (3rd ed.) (DSM-III) diagnoses and statistically derived syndromes was examined within a community sample of children and adolescents in Puerto Rico. Specifically, the extent to which behavior dimensions, derived from the Child Behavior Checklist and the Youth Self-Report, corresponded to psychiatric diagnoses, derived from parent and child versions of the Diagnostic Interview Schedule for Children, was examined. The alternative approaches for assessing psychopathology in children and adolescents were compared against external validators. The results indicated a meaningful convergence between DSM-III diagnoses and statistical syndromes; however, a one-to-one correspondence did not emerge. Little evidence was found for diagnostic thresholds. There was no evidence of the superiority of either the statistically derived syndromes or the DSM-III diagnoses. The incorporation of a measure of impairment improved the validity of both approaches. Adding parental reports to the selfreports of adolescents yielded little gain in the validity of either the statistical or diagnostic approach. The implications for the definition and assessment of child and adolescent disorders are discussed.This research was supported by grant MH 38821 from the National Institute of Mental Health.The authors wish to acknowledge Glorisa Canino, Ph.D., and Maritza Rubio-Stipec, M.A., of the University of Puerto Rico, co-investigators in the epidemiologic project and to Barbara Bettes, Ph.D. for her contribution to preliminary analyses for this manuscripl. Portions of this paper were presented at the 38th Annual Meeting of the American Academy of Child and Adolescent Psychiatry, San Francisco, October 1991.     

Convergence of parent checklists and child psychiatric diagnoses

This study examined the correlation between the Childrens' Behavior Questionnaire by Rutter, Tizard, and Whitmore (1970) and clinical diagnoses in a total of 1,468 in-and outpatients. The following diagnoses were considered: conduct disorder, emotional disorder, mixed disorder of conduct and emotions, and the hyperkinetic syndrome. In general, correlations were low, but subscores indicating conduct or neurotic disorders had somewhat higher correlation with these respective disorders than the hyperactivity subscore. Sensitivity figures (i.e., percentage of true positives) were moderate to low, while specificity figures (i.e., percentage of true negatives) were high. It is concluded that convergence of parent checklists and child psychiatric diagnoses in unselected samples is only moderate.     

Distribution of DSM-II diagnoses in a child psychiatric setting

While DSM-II contains more diagnostic categories related specifically to children than did the earlier DSM-I, clinical utilization studies of the various categories have not been extensive. The present study reports data on the distribution of diagnoses of childhood disorders and analyzes relationships among several diagnostic categories and subject variables. Results indicate that clinicians are using a wide range of DSM-II diagnoses for childhood disorders, including some which were intended for use with adults as well as those which were designed specifically for children. Transient Situational Disorders and Behavior Disorders are assigned almost equally to two-thirds of the sample. Chi-square analyses revealed a relationship between diagnostic categories and subject variables of age and sex. These data suggest that boys, particularly between the ages of 6 and 13, are more frequently than girls categorized as Behavior Disorder, and that the Transient Situational Disorder category is overutilized for adolescents, both male and female.The authors are indebted to James H. Johnson for his valuable contributions in all phases of this study and to Peggy Louro for her assistance in data collection.     

Convergence of clinically derived diagnoses and parent checklists among inpatient children

The extent to which parent rating scales differentiated children according to DSM III diagnoses was examined. A total of 113 psychiatric inpatient boys (ages 6–11) were rated by their mothers or maternal figures on the Child Behavior Checklist (CBCL) and the Behavior Problem Checklist (BPC). Children with DSM III diagnoses of conduct disorder or depression were compared to children without these diagnoses. Externalizing and internalizing scales of the parent checklists and additional measures of child aggression and depression differentiated children according to major diagnoses. The use of parent checklists to classify children indicated a high level of sensitivity for both CBCL and BPC scales for diagnosing conduct disorder and depression. However, specificity of the subscales, particularly for the CBCL, was relatively low, indicating a high rate of false positives. The need for further work that extends the range of diagnosis, that examines subtypes of disorders, and that increases the specificity of the measures for diagnostic purposes is discussed.Completion of this project was supported by a Research Scientist Development Award (MH00353) and a grant (MH35408) from the National Institute of Mental Health, and by a Clinical Research Center Grant for the Study of Affective Disorders (5 P50 MH30915) from the National Institute of Mental Health. The authors are grateful to Elaine Meyer, Karen Esveldt-Dawson, Antoinette Rodgers, and the clinical research team and staff of the Child Psychiatric Treatment Service.     

The normative development of child and adolescent problem behavior

The aim of this study was to identify normative developmental trajectories of parent-reported problems assessed with the Child Behavior Checklist (CBCL; T. M. Achenbach, 1991) in a representative sample of 2,076 children aged 4 to 18 years from the general population. The trajectories were determined by multilevel growth curve analyses on the CBCL syndromes in a Longitudinal multiple birth-cohort sample that was assessed 5 times with 2-year intervals. Most syndromes showed a linear increase or decrease with age or a curvilinear trajectory, except for thought problems. Trajectories for most syndromes differed for boys versus girls, except those for withdrawn, social problems, and thought problems. These normative developmental trajectories provide information against which developmental deviance in childhood and adolescence can be detected.     

Early abuse, psychiatric diagnoses and irritable bowel syndrome

In a population of 71 (57 female, 14 male) IBS patients seeking psychological treatment, we found expected levels of childhood sexual and physical abuse (57.7%) and expected levels of current Axis I psychiatric disorders (54.9%). Moreover, we found those who had been victims of early abuse had higher current Beck Depression Inventory scores. However, contrary to expectations, there were no significant associations between early abuse and current psychiatric disorder in this population, suggesting that those individuals with psychological distress are not exactly the same group with a history of abuse.     

Replication of empirically derived syndromes as a basis for taxonomy of child/adolescent psychopathology

To advance the empirical identification of child/adolescent syndromes, principal components analyses were performed on four sets of parents' ratings of 8,194 6- to 16-year-olds referred to American and Dutch mental health services. The following syndromes replicated well for both sexes at ages 6-16: Aggressive, Anxious/Depressed, Attention Problems, Delinquent, Somatic Complaints, and Withdrawn. For both age ranges, a syndrome designated as Socially Inept replicated well among boys, and one designated as Mean replicated well among girls. Evidence was also found for a Schizoid syndrome in all sex/age groups and a Sex Problems syndrome among girls at ages 6-11. Syndrome scores discriminated well between nationwide normative and clinical samples. The replicated syndromes contribute to the empirical basis for a taxonomy of the kinds of disorders commonly seen between the ages of 6 and 16.     

The interview for antisocial behavior: Psychometric characteristics and concurrent validity with child psychiatric inpatients

The present study evaluated psychometric features and correlates of the Interview for Antisocial Behavior (IAB), a new measure designed to assess antisocial child behavior. Parents of 264 psychiatric inpatients (ages 6–13 years) completed the measure to evaluate antisocial behavior of their children. The investigation evaluated the relation of IAB scores to clinically derived diagnoses and to aggression and externalizing behaviors, as measured by different raters (parents, teachers), across different settings (home, school, hospital), and with different assessment methods (rating scales, behavioral role-play test). The results indicated that the IAB showed acceptable levels of internal consistency. A priori scores (severity, duration, total antisocial behavior) and factor analytically derived scales (Arguing/Fighting, Covert Antisocial Behaviors, Self-Injury) distinguished children with a DSM III diagnosis of conduct disorder, and scores on the IAB were more consistently related to other measures of aggression and externalizing behavior than to measures of internalizing behavior or overall severity of dysfunction. The implications of the results for use of the measure, particularly in relation to evaluation of the overt-covert dimension of antisocial behavior, are discussed.Completion of this research was facilitated by a Research Scientist Development Award (MH00353) and by grants (MH35408, MH39642) from the National Institute of Mental Health and the Rivendell Foundation.     

Making faces: testing the relation between child behavior problems and mothers' interpretations of child emotion expressions

We examined the relations between preschool boys' behavior problems and mothers' interpretations of children's emotion expressions. A sample of 31 mothers of oppositional boys and 28 control mothers responded to standard stimuli depicting child emotional reactions to maternal control attempts; mothers were instructed to think of the stimuli as either (a) their own child or (b) an unfamiliar child. Mothers of oppositional boys were more likely to generate negative interpretations than were control mothers when thinking of their own children; however, this difference did not generalize to the explicitly unfamiliar child condition. Mothers of oppositional boys demonstrated negative and comparison mothers demonstrated positive interpretive tendencies toward their own children. Findings suggest that child emotion cues may trigger biased maternal cognitions even in the absence of child misbehavior.     

The utility of differentiating between mixed and pure forms of antisocial child behavior

This study examined the utility of classifying boys on the basis of a typology of antisocial behavior. A group of 195 boys, aged 10–17, was divided into four mutually exclusive groups based on their pattern of antisocial behavior. Stealing and fighting were chosen as criteria to define the four groups: (a) boys who fought but did not steal (Exclusive Fighter Group), (b) boys who stole but did not fight (Exclusive Theft Group), (c) boys who stole and fought (Versatile Antisocial Group), and (d) boys who did neither (Remaining Group). A multimethod-multirespondent study of these boys showed that (a) the Exclusive Fighter Group tended to score high on a range of overt antisocial behaviors and were relatively little involved in delinquency; (b) the Exclusive Theft Group tended to score high on some overt antisocial behaviors and were much involved in delinquency; (c) Versatile Antisocial youths scored highest among all groups on almost all overt and covert antisocial behaviors, and in terms of delinquent acts. The Versatile boys came from families with the most disturbed child-earing practices.The authors are indebted to Gerald Patterson for his inspiration and encouragement through-out the study. They acknowledge the most helpful comments they have received during earlier drafts of this paper from Drs. John Reid, Magda Stouthamer-Loeber, and Mark Weinrott.The paper was presented at the annual meeting of the American Society of Criminology, Denver, Colorado, November 10, 1983. The study has been funded by the Center for Studies in Crime and Delinquency, National Institute of Mental Health, Grants MH 32857 and MH 37940.     

The relationship between predictability and problem behavior for students with severe disabilities

Two single-case studies were conducted to examine the extent to which signaled (predictable) and unsignaled (unpredictable) events were associated with changes in the level of problem behavior during instruction. Two students with moderate-to-severe intellectual disabilities and autism participated in the study. Each student was nominated for the study based on a teacher's report that problem behaviors were much more likely when novel or unsignaled events occurred. Functional assessments were conducted with each student and the specific predictability features (signals) associated with low and high levels of problem behavior were identified. Multi-element and reversal designs were employed to examine the extent to which increased predictability was associated with reduced problem behavior. Results supported the use of functional assessment procedures to determine whether signals that provide information about the content, duration, timing, and/or consequences of future events could reduce problem behaviors.     

The association between axis I and II psychiatric symptoms and high-risk sexual behavior during adolescence

This study was conducted to investigate the association between psychiatric disorders and high-risk sexual behavior among adolescent primary care patients. Interviews assessing anxiety, conduct, depressive, eating, substance use, and personality disorders (PDs), as well as histories of sexual behavior were administered to 119 male and 284 female adolescent primary care patients. Results indicated that, after co-occurring psychiatric disorders were controlled statistically, adolescents with elevated PD symptom levels were more likely than adolescents without elevated PD symptom levels to report a high number of sexual partners during the past year and during their lifetime. Adolescents with a history of conduct disorder were more likely than adolescents without such a history to report a high number of lifetime unsafe sexual partners. Elevated antisocial, dependent, and paranoid PD symptom levels were associated with high-risk sexual behavior after co-occurring psychiatric disorders were controlled. Further, certain specific antisocial, borderline, dependent, histrionic, narcissistic, obsessive-compulsive, paranoid, and schizotypal PD symptoms were independently associated with high-risk sexual behavior after co-occurring psychiatric disorders and overall PD symptom levels were controlled. The association between overall PD symptom levels and the number of sexual partners was significantly stronger among the females than among the males in the sample. Increased recognition and treatment of PDs, coupled with increased recognition of high-risk sexual behavior may facilitate the prevention of sexually transmitted diseases and teenage pregnancy among adolescents.     

Locus of control and achievement in child psychiatric inpatients

The relationship between the Nowicki-Strickland Locus of Control Scale for Children (Nowicki & Strickland, 1973) and academic achievement was examined in a sample of 66 child psychiatric inpatients. Previous studies had suggested that this measure correlated with achievement in normal samples (Nowicki & Strickland, 1973) but not in populations of male juvenile offenders (Little & Kendall, 1978). The product-moment correlation between the Nowicki-Strickland Scale and the Peabody Individual Achievement Test was significant. However, when the effect of IQ was controlled for in a partial correlation, there was no significant correlation. Discussion focuses on the relationship between these results and other findings in the area of locus of control, intelligence, and achievement.     

Personality processes and problem behavior

This article introduces the special issue of Journal of Personality on personality and problem behavior. There is growing evidence that various dimensions of personality are associated with a broad range of problem behaviors such as drug and alcohol use, sexual risk-taking, interpersonal violence, and gambling. To date, research on personality and problem behavior has focused almost exclusively on documenting simple, direct associations between personality traits and problem behaviors. This article proposes an expanded research agenda, a second generation of research and theory on the role of personality in problem behavior. The agenda specifies two major classes of second-generation hypotheses. Moderator hypotheses concern the conditions under which the influence of personality on problem behavior is magnified, weakened, or eliminated. Mediator hypotheses concern the causal processes that underlie the influence of personality on problem behavior. Articles in the special issue, which are summarized in this introduction, exemplify the proposed second generation of research on personality and problem behavior.     

Methodological considerations in the evaluation of the convergence of psychiatric diagnoses and parent-informant checklists

Psychiatric diagnoses and objective parent checklists are alternative ways to describe child adjustment problems. There has recently been interest in evaluating the degree of agreement or convergence between these sources of information. This paper addresses three issues neglected by researchers in this area. The appropriateness of the use of indices of sensitivity and specificity to describe the correspondence of diagnoses and checklist scores is questioned. Implications of failure to consider the reliability of diagnoses in interpreting diagnosis-checklist agreement are discussed. Also, possible parameters of diagnosis-checklist agreement that should be identified by researchers are reviewed. Suggestions for improving research in this area are offered.     

Development of a structured psychiatric interview for children: Agreement between child and parent on individual symptoms

To test the reliability of children's reporting as compared with that of their mothers, a highly structured psychiatric diagnostic interview was used with 307 subjects, ages 6 through 16. Another interviewer gave each mother a similar interview about the child. Responses of each mother-child pair to 168 questions were compared using the kappa statistic. Highest agreement was found on questions concerning symptoms that are concrete, observable, severe, and unambiguous. Mothers tended to report significantly more behavioral symptoms, and children more subjective symptoms. Reasons for low kappas and asymmetrical reporting of symptoms are discussed.     

Depression in child psychiatric inpatients: Cognitive and attributional patterns

Cognitive and learned helplessness models of depression view maladaptive cognitive and attributional patterns as core features of depressive disorders. This study examined cognitive and attributional patterns in depressed children, nondepressed children, and a subgroup of remitting depressives who had histories of depression but were not reporting depressive symptoms when evaluated during the first 2 weeks of hospitalization. When compared with nondepressed controls, depressed children reported significantly more hopelessness, more negative self-perceptions, and negative self-perceptions across a wider variety of domains, and they displayed more dysfunctional attributional styles. While 55% of depressed children displayed pervasive maladaptive cognitive patterns, the other 45% of depressed children scored more similarly to nondepressed children, suggesting that childhood depressive disorders may be heterogeneous with respect to cognitive patterns. Contrary to the notion of traitlike depressive cognitive and attributional patterns that persist after the remission of depressive episodes, children with remitting depressions scored similarly to nondepressed children.Partial support for this project was provided by a grant from the John D. and Catherine T. MacArthur Foundation as part of their Network on Risk and Protective Factors in the Major Mental Disorders. I wish to thank Donald Guthrie for providing statistical consultation, Gwen Gordon for her computer assistance, and Niels Mueller and Jean Keller for their help with data collection.     

The frequency and significance of additional self-reported psychiatric diagnoses in children with attention deficit disorder

The frequency of additional self-reported diagnoses in a large, heterogeneous sample of attention defiict disorder (ADD) children (N=182)was determined using the Diagnostic Interview for Children and Adolescents (DICA). Over half the children had additional DICA diagnoses, with oppositional disorder and anxiety/mood disorders the most frequent. ADD boys with internalizing-type diagnoses had lower verbal IQs and arithmetic scores and performed more poorly on attention tasks than those without; parents also rated them more adversely. Those with externalizing- type diagnoses were rated as more aggressive by teachers and had sociopathic, thrill- seeking profiles on paper-pencil self-ratings. Over 40% of the children were dyslexic or slow learners but they had no higher rate of DICA diagnoses than those who read adequately.This research was supported by NIMH grant R01-MH39189 and by the Marie Wilson Howells Fund. The authors are grateful to the Chid Study Center staff who assisted in recruiting and evaluating subjects and to the Behavioral Laboratory team members who collected and analyzed the data.