Schedule for affective disorders and schizophrenia for school-age children (K-SADS-PL) for the assessment of preschool children – A preliminary psychometric study
Introduction
There is a growing awareness that anxiety, depression, and behavioral disorders occur in preschool children (Egger and Angold, 2006, Gadow et al., 2001, Henin et al., 2005, Keenan et al., 1997, Lavigne et al., 1996, Luby et al., 2004a, Roberts et al., 1998) with the prevalence of “any psychiatric disorders” ranging from 16% to 26% in 2–5 year old preschool children in non-psychiatric settings (Egger and Angold, 2006).
With growing awareness of the intergenerational transmission of major psychiatric disorders, and demonstration of temperamental and biological differences in young children at risk for these disorders, identification of the earliest manifestation of disorder is extremely important, both for purposes of research, and with regard to prevention and treatment.
Current interviews for the assessment of psychopathology in preschoolers include the preschool age psychiatric assessment (PAPA; Egger and Angold, 2004, Egger et al., 2006) and the diagnostic interview schedule for children version IV, modified for young children (DISC-IV-YC; Lucas et al., 1998). Both of these instruments are fully-structured interviews and the diagnoses are generated through a computer algorithm. Thus, the addition of a semi-structured diagnostic interview which mimics the regular clinical interview and whose final diagnoses are done through a diagnostic consensus, such as the schedule for affective disorders and schizophrenia for school-age children present and lifetime version (K-SADS-PL) (Kaufman et al., 1997), will give extra flexibility to the clinicians/researchers to further evaluate the differential diagnosis of each symptom in the context of the normal development and the environment of the child. This would provide a valuable additional tool for the assessment of psychopathology in preschoolers. Moreover, since the K-SADS is widely used for children and adolescents ages 6–18 years old, using the same instrument to longitudinally assess a child from the preschool years through adolescence would enhance data collection and analysis. The use of the K-SADS in preschoolers would therefore reduce method variance in trying to establish continuity and discontinuity between preschool and later childhood conditions, and also would be useful in defining the limits of phenotypes, given emerging evidence of very early manifestations of anxiety, mood, and other disorders (Egger and Angold, 2006).
The K-SADS-P (present version) has been used to ascertain specific diagnoses including oppositional defiant disorder (ODD) and conduct disorder (CD) (Keenan and Wakschlag, 2004, Kim-Cohen et al., 2005); attention deficit hyperactivity disorder (ADHD) (Lahey et al., 1998); major depressive disorder (MDD) (Luby et al., 2003), dysthymic disorder (Kashani et al., 1997), and post-traumatic stress disorder (PTSD) (Scheeringa et al., 2001). Also, few studies have used the K-SADS-E (epidemiological version) (Orvaschel, 1994) as a tool to interview parents about possible psychopathology in preschool children (Keenan and Wakschlag, 2004, Henin et al., 2005). However, with the exception for the psychometrics of the K-SADS-P for some of the above-noted specific disorders, the psychometrics of the K-SADS-PL for the ascertainment of psychiatric disorders in preschoolers has not been widely evaluated.
The purpose of this pilot study was to extend prior K-SADS preschool studies assessing the psychometrics for general psychopathology of preschool children as reported by their parents using the K-SADS-PL. Since it is important not to only evaluate the convergent and divergent validity of the diagnoses generated through the K-SADS-PL against instruments that yield categorical diagnoses such as the early childhood inventory-4 (ECI-4) (Gadow and Sprafkin, 1997, Gadow et al., 2001, Sprafkin et al., 2002), the K-SADS-PL will be compared with a dimensional instrument, the child behavior checklist for ages 1½–5 years (CBCL; Achenbach and Rescorla, 2000). This is particularly important because clinically significant individual symptoms that present at an early age but do not meet full threshold for a diagnostic and statistical manual-IV (DSM-IV; APA, 1994) disorder may herald the development of future syndromic psychopathology. For the same reason, we will also evaluate the psychometrics of the K-SADS-PL screens (see Section 2). It was hypothesized that the K-SADS-PL will show good psychometric properties and could be reliably used with preschoolers. Children with mood/anxiety symptoms will show similar diagnoses in the ECI-4 and significantly higher scores in the internalizing and respective subscales of the CBCL, and lower scores in the externalizing subscales of the CBCL. In contrast, children with behavioral disorders will have higher scores on the externalizing subscale of the CBCL and more disruptive disorders in the ECI-4.
Section snippets
Subjects
The sample consisted of 2- to 5-year-old children of parents with and without psychopathology consecutively recruited for an ongoing National Institute of Mental Health (NIMH)-funded study, the bipolar offspring study (BIOS) (MH 60952, Principal Investigator: Boris Birmaher). These children were recruited from parents with bipolar disorder mainly ascertained through advertisement and from a random community control sample of community parents. The results of the comparison of these two groups
Statistical analyses
Study outcomes were assessed by standard parametric and non-parametric statistics (e.g., χ2, Mann Whitney U). Convergent and divergent validity were evaluated through Spearman’s (rho) correlations. Effect size (ES) for independent groups was calculated by Cohens’ d. Inter-rater reliability was assessed using the kappa statistic for n ⩾ 2 raters (Fleiss, 1981). Differences between two correlated correlation coefficients were tested using a modified Fisher z transformation method (Meng et al., 1992
Definite lifetime DSM-IV axis-I diagnoses
Using the K-SADS-PL, 22% (46/204) of the sample had a definite DSM-IV axis-I diagnosis, with 13% (26/204) having one disorder; 6% (12/204) two disorders, and 4% (8/204) three or more disorders. As shown in Table 1, the most prevalent lifetime definite disorders were attention deficit hyperactivity disorder (ADHD) (mainly the impulsive/hyperactive type) (9.8%, 20/204), oppositional defiant disorder (ODD) (8.3%, 17/204), any emotional disorders (mood and anxiety disorders (8.8%, 18/204), any
Discussion
The results of this study replicate and extend the current literature and suggest that the K-SADS-PL may be used as a reliable tool for the evaluation of DSM-IV psychiatric disorders in preschoolers. As hypothesized, in general the K-SADS-PL showed good psychometric properties for the screening and diagnosis of DSM-IV disorders in this population of children. Moreover, as reviewed by Egger and Angold (2006), the lifetime prevalence of any DSM psychiatric disorders and specific disorders (e.g.,
Role of the funding source
The project described was supported by Grant Number MH60952 (PI: Boris Birmaher, M.D.) from the National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health.
Conflict of interest
Disclosures: Dr. Birmaher has participated at forums sponsored by JAZZ Pharmaceuticals and Abcomm, Inc. He also receives royalties from Random House for his book “New Hope for Children and Teens with Bipolar Disorder”. All other authors declare that they have no conflicts of interest.
Contributors
Boris Birmaher, M.D. designed, wrote and administered the study and supervised the coordinators and interviewers. Dr. Birmaher wrote and revised the paper. Mary Ehmann, M.A. performed the analyses of the paper and wrote the first drafts of the paper. David A. Axelson, M.D. helped to design and administer the study. Dr. Axelson supervised the interviewers and revised the analyses and the paper. Benjamin I. Goldstein, M.D, Ph.D. helped to supervise the interviewers and revised the paper. Kelly
Acknowledgments
The authors thank Mrs. Carol Kostek for her assistance with manuscript preparation, the data staff (Amy Broz, Mary Beth Hickey, Nicole Ryan) and the interviewers.
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