Older adult psychopathology: international comparisons of self-reports, collateral reports, and cross-informant agreement.

OBJECTIVES: To conduct international comparisons of self-reports, collateral reports, and cross-informant agreement regarding older adult psychopathology. PARTICIPANTS: We compared self-ratings of problems (e.g. I cry a lot) and personal strengths (e.g. I like to help others) for 10,686 adults aged 60-102 years from 19 societies and collateral ratings for 7,065 of these adults from 12 societies. MEASUREMENTS: Data were obtained via the Older Adult Self-Report (OASR) and the Older Adult Behavior Checklist (OABCL; Achenbach et al., ). RESULTS: Cronbach's alphas were .76 (OASR) and .80 (OABCL) averaged across societies. Across societies, 27 of the 30 problem items with the highest mean ratings and 28 of the 30 items with the lowest mean ratings were the same on the OASR and the OABCL. Q correlations between the means of the 0-1-2 ratings for the 113 problem items averaged across all pairs of societies yielded means of .77 (OASR) and .78 (OABCL). For the OASR and OABCL, respectively, analyses of variance (ANOVAs) yielded effect sizes (ESs) for society of 15% and 18% for Total Problems and 42% and 31% for Personal Strengths, respectively. For 5,584 cross-informant dyads in 12 societies, cross-informant correlations averaged across societies were .68 for Total Problems and .58 for Personal Strengths. Mixed-model ANOVAs yielded large effects for society on both Total Problems (ES = 17%) and Personal Strengths (ES = 36%). CONCLUSIONS: The OASR and OABCL are efficient, low-cost, easily administered mental health assessments that can be used internationally to screen for many problems and strengths.

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

OBJECTIVE: To prospectively examine the association between mode of delivery and childhood psychopathology. DESIGN: Retrospective cohort study. SETTING: Eighteen counties and three cities in China. POPULATION: A total of 4190 preschool children whose mothers were registered in a perinatal surveillance programme were assessed with the Child Behaviour Checklist (CBCL), an instrument to assess child emotional (internalising) and behavioural (externalising) problems. METHODS: Differences in CBCL problem scores were analysed both quantitatively and categorically among children born by caesarean delivery on maternal request (CDMR), assisted vaginal delivery (AVD), and spontaneous vaginal delivery (SVD). MAIN OUTCOME MEASURES: The CBCL total, externalising, and internalising scores. RESULTS: There were significant differences in the mean scores of total (20.9, 23.0, and 25.0), externalising (7.6, 8.4, and 9.1), and internalising (4.7, 5.2, and 5.6) problems among children born by CDMR, SVD, and AVD, after adjusting for potential confounding factors (P = 0.007, 0.014, and 0.031). Children born by AVD were more likely than those born by SVD to have total (OR 1.43; 95% CI 1.10-1.86), externalising (OR 1.46; 95% CI 1.11-1.92), and internalising (OR 1.41; 95% CI 1.08-1.84) scores in the highest quartile, whereas children born by CDMR were less likely to have externalising scores in the highest quartile (OR 0.64; 95% CI 0.42-0.97). Furthermore, there were significant increasing linear trends on all problem scores, and in the odds of being in the highest quartile, from children born by CDMR to those born by SVD and AVD. CONCLUSION: The likelihood of childhood psychopathological problems may be the lowest in children born by CDMR, followed by those born by SVD, whereas the highest probability was observed in those born by AVD.

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

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

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

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

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

OBJECTIVE: Comorbidity of psychiatric problems such as anxiety and depression poses challenges to treatment and research. This study tested whether problem items from the Anxious/Depressed scale of the Child Behavior Checklist (CBCL) can be separated into distinct anxiety and depression classes or are continuously distributed throughout a population. METHOD: A CBCL was completed by a parent or guardian of each of 1,987 children and adolescents selected to represent nonreferred children in the United States, as well as by a parent or guardian of each of a demographically matched sample of 1,987 clinically referred children and adolescents. Problem items from the Anxious/Depressed scale of the CBCL were subjected to latent class analysis. RESULTS: Analyses revealed three levels of problem presentation in both samples. Children in the nonreferred sample were classified as having no problems, mild problems, or moderate anxiety/depression problems. Children and adolescents in the referred group were classified as having mild, moderate, or severe levels of problems. No pure anxiety or depression classes were found, only classes containing a mixture of both anxiety and depressive problems. Age, gender, and sample differences were found in class groupings, with nonreferred adolescent girls showing elevated levels of problems. CONCLUSIONS: Results suggest that the comorbid conditions of anxiety and depression, as assessed by the CBCL anxiety/depression problem items, can be thought of as part of the same continuum of problems. Implications for assessment and treatment utilization are discussed.

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

OBJECTIVE: To test whether attention problems predicted different signs of disturbance than conduct problems over 3 and 6 years. METHOD: Gender-specific criteria for deviance on parents' ratings of attention versus conduct problems were tested as predictors of interview-reported signs of disturbance in a national sample first assessed at ages 4 to 16 years. RESULTS: Males and females deviant on both attention and conduct problems showed higher rates of several signs of disturbance than did those deviant on only one type of problem. Subjects deviant only on conduct problems showed higher rates of several signs than did controls, whereas those deviant only on attention problems exceeded controls mainly on special education services. Unaggressive "delinquent" conduct problems predicted dropping out of school, unwed pregnancy, and total signs for both genders during transitions to adulthood. CONCLUSIONS: Attention problems predict receipt of special education but contribute much less than conduct problems to predicting other signs of disturbance. Differential assessment of aggressive versus unaggressive conduct problems can improve prediction, as can gender specificity in setting criteria for deviance and in testing outcomes.

Latent class analysis of Child Behavior Checklist attention problems.

OBJECTIVE: To test whether attention problems in children are continuously distributed or categorically discrete, the authors performed latent class analyses (LCA) of items from the Attention Problems scale of the Child Behavior Checklist (CBCL) using data from the clinical and nonclinical samples used in the derivation of the CBCL syndromes. METHOD: A CBCL was completed by a parent or guardian of each of 2,100 nonreferred children selected to be representative of U.S. nonreferred children and a demographically matched sample of 2,100 clinically referred children. Attention problems symptoms were subjected to LCA. RESULTS: LCAs were consistent with the presence of 3 levels of symptom presentation in both samples. Children in the nonclinical sample were classified as having no symptoms, mild symptoms, or moderate symptoms. Children in the clinical group had mild, moderate, or severe symptoms. CONCLUSIONS: These results suggest that child and adolescent psychiatric symptoms such as attention problems can be thought of as continuously distributed phenomena rather than discrete disease entities, lending support for an empirical approach to both clinical work and research. In addition, high prevalence rates of attention problems in both clinical and nonclinical samples suggest the need for careful screening of attention problems in clinic and academic settings.

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

OBJECTIVE: The purpose of this study was to compare syndromes of parent-reported problems for children in 12 cultures. METHOD: Child Behavior Checklists were analyzed for 13,697 children and adolescents, ages 6 through 17 years, from general population samples in Australia, Belgium, China, Germany, Greece, Israel, Jamaica, the Netherlands, Puerto Rico, Sweden, Thailand, and the United States. RESULTS: Comparisons of nine cultures for subjects ages 6 through 17 gave medium effect sizes for cross-cultural variations in withdrawn and social problems and small effect sizes for somatic complaints, anxious/depressed, thought problems, attention problems, delinquent behavior, and aggressive behavior. Scores of Puerto Rican subjects were the highest, whereas Swedish subjects had the lowest scores on almost all syndromes. With great cross-cultural consistency, girls obtained higher scores than boys on somatic complaints and anxious/depressed but lower scores on attention problems, delinquent behavior, and aggressive behavior. Although remarkably consistent across cultures, the developmental trends differed according to syndrome. Comparison of the 12 cultures across ages 6 through 11 supported these results. CONCLUSIONS: Empirically based assessment in terms of Child Behavior Checklist syndromes permits comparisons of problems reported for children from diverse cultures.

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

OBJECTIVE: To identify adolescent predictors of young adult signs of disturbance. METHOD: Family variables and parent- and self-reported syndromes, competencies, and stressful experiences were tested as predictors of school dropout, unwed pregnancy, substance use, mental health services, suicidal behavior, police contacts, and being fired from jobs. RESULTS: Most signs were predictable with considerable accuracy, especially suicidal behavior and being fired from jobs among females. The Delinquent Behavior syndrome and poor school functioning predicted the most poor outcomes. Concurrent scores on young adult syndromes were significantly associated with most signs. CONCLUSIONS: Across the diversity of a national sample, young adult signs of disturbance were predictable from risk and protective factors assessed in adolescence. The predictors can help to identify youth at risk for particular signs. Parents are important contributors to assessment of young adults' problems.

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

OBJECTIVE: To compare parent-reported problems for children in 12 cultures. METHOD: Child Behavior Checklists were analyzed for 13,697 children and adolescents, aged 6 through 17 years, from general population samples in Australia, Belgium, China, Germany, Greece, Israel, Jamaica, the Netherlands, Puerto Rico, Sweden, Thailand, and the United States. RESULTS: Comparisons of 12 cultures across ages 6 through 11 and 9 cultures across ages 6 through 17 yielded medium effect sizes for cross-cultural variations in Total Problem, Externalizing, and Internalizing scores. Puerto Rican scores were the highest, while Swedish scores were the lowest. With great cross-cultural consistency, Total and Externalizing scores declined with age, while Internalizing scores increased; boys obtained higher Total and Externalizing scores but lower Internalizing scores than girls. Cross-cultural correlations were high among the mean item scores. CONCLUSIONS: Empirically based assessment provides a robust methodology for assessing and comparing problems reported for children from diverse cultures. Age and gender variations are cross-culturally consistent. Although clinical cutoff points should not necessarily be uniform across all cultures, empirically based assessment offers a cost-effective way to identify problems for which children from diverse cultural backgrounds may need help.

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

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

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

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

Accelerated longitudinal comparisons of aggressive versus delinquent syndromes.

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

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

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

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

OBJECTIVE: To test the extent to which attention problems, the continuation of early comorbid conduct problems, and overall initial problems account for poor outcome scores on the Child Behavior Checklist and related measures 3 and 6 years after initial assessment. METHOD: The course of attention and conduct problems was investigated in a nationally representative US sample assessed three times over 6 years, using standardized ratings of attention, conduct, and other problems and gender-specific scores for defining deviance. RESULTS: Subjects deviant on both attention and conduct problems scored significantly higher on behavior problems at outcome than did those deviant on only attention problems or conduct problems. After controlling for initial conduct problems, initial attention problems made little unique contribution to later conduct problems. Predictive patterns were similar across gender and age groups. CONCLUSIONS: Both boys and girls who show a combination of attention and conduct problems are at particular risk for the persistence of conduct problems.

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

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

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

OBJECTIVE: To test developmental paths from adolescent syndromes and other candidate predictors to young adult syndromes. METHOD: A national sample assessed at ages 13 through 16 and 16 through 19 years was reassessed at 19 through 22 years in terms of six syndromes derived empirically from parent and self-reports, two syndromes derived only from parent reports, and one derived from self-reports. RESULTS: Several young adult syndromes were similar to adolescent syndromes and were strongly predicted by these syndromes. A new syndrome designated as Shows Off and an adult Aggressive Behavior syndrome were both predicted by the adolescent Aggressive Behavior syndrome. This indicates a developmental transition away from overt aggression among some aggressive youths but not others. A syndrome designated as Irresponsible was predicted by the adolescent Attention Problems syndrome and may be an adult phenotype of attention deficit disorder. Surprisingly, attention problems were associated with more diverse problems among females than males. CONCLUSIONS: There are strong predictive relations from adolescent to adult syndromes. Sex differences in predictive paths argue against basing assumptions about both sexes on findings for one sex.

Empirically based assessment and taxonomy of psychopathology: cross-cultural applications. A review.

This paper provides an overview of empirically based assessment and taxonomy, as illustrated by cross-cultural research on psychopathology. The empirically based approach uses standardized assessment procedures to score behavioral and emotional problems from which syndromes are derived by multivariate analyses. Items and syndromes are scored quantitatively to reflect the degree to which individuals manifest them, as reported by particular informants. Although the approach to assessing problems and to constructing taxonomic groupings differs from the ICD/DSM approach, there are no inherent contradictions between either their models for disorders nor the criterial features used to define disorders. Cross-cultural comparisons have yielded relatively small differences in problem rates and syndrome structure, plus considerable similarity in associations of problems with sex and SES, as well as similar correlations between reports by different types of informants. Research on variations in problems in relation to culture, sex, age, SES, and type of informant can contribute to improving both the ICD/DSM and empirically based approaches and to a more effective synthesis between them.