Академический Документы
Профессиональный Документы
Культура Документы
discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/12373549
CITATIONS
READS
587
945
5 AUTHORS, INCLUDING:
Tamsin Jane Ford
University of Exeter
157 PUBLICATIONS 5,161 CITATIONS
SEE PROFILE
Introduction
The Development and Well-Being Assessment
(DAWBA) is an integrated package of measures of child
and adolescent psychopathology. It was initially designed
for a nationwide epidemiological survey of common
emotional and behavioural disorders in a representative
sample of over 10,000 British children and adolescents,
with the primary aim of informing the planning and
provision of services for affected children (Meltzer,
Gatward, Goodman, & Ford, 2000). Drawing upon
Requests for reprints to: Professor Robert Goodman, Department of Child and Adolescent Psychiatry, Institute of
Psychiatry, De Crespigny Park, London SE5 8AF, U.K.
645
646
R.GOODMAN et al.
Method
0ver view
The DAWBA measures were administered along with independent measures of mental health and service provision to
samples of 5-15-year-olds drawn from the community and from
psychiatric clinics. All assessments were carried out between
January and March, avoiding the autumn term when teachers
do not yet know their pupils well, and avoiding the summer
term when teachers are often caught up in end-of-year examinations. The diagnosis of clinic cases was independently established by a review of case notes. Most of the community
sample was followed up by questionnaire between 4 and
6 months later.
Community Sample
In order to pilot a nationwide survey ofchildren and teenagers
aged between 5 and 15, the Office for National Statistics used
experienced nonclinical interviewers to carry out a survey of
children drawn from 12different areas in England and Scotland.
Children in each area were identified from child benefit records;
child benefits are available without means testing and are
claimed on behalf of around 98 % of British children. Parents of
a random sample of children were invited to participate via the
Child Benefit Office, and 5 % opted out at this stage. Of the
remainder, 471 participated in the pilot study, representing
82 % of those approached (15 YOrefusal, 3 YOnoncontacts). The
pilot community sample consisted of these 471 individuals plus
an additional 20 community subjects who had participated a
year earlier in a pre-pilot survey, having been located through
household sampling (Goodman, Meltzer, & Bailey, 1998). A
parent interviewwas available for all but 1of the 491 community
subjects. There were 207 subjects aged between 11 and 15, of
whom 201 (97 %) were interviewed.Nearly all 491 families gave
647
648
R. GOODMAN et al.
649
Questionnaire Follow-up
Results
Comparing Community and Clinic Samples
The first analytic strategy used to examine the validity
of the DAWBA involved a comparison of the clinical and
community samples on rates of DAWBA-diagnosed
disorders. The only assumption underlying this comparison was that the true rate of psychiatric disorder was
substantially higher in the clinic than in the community
sample, so that demonstrating contrasting rates with the
Table 1
Rates of D A W B A Diagnoses in Community and Clinic Children
Any disorder"
Anxiety disorder"
Major depressive disorder"
Conduct-oppositional disorders"
Hyperkinesisb
ADHD'
Psychiatric clinic
sample ( N = 39)
Community
sample ( N = 491)
Odds
ratio
92.3 Yo (36)
43.6% (17)
20.5% (8)
46.2 'Yo (18)
41.0% (16)
48.7% (19)
10.6% (52)
5.5 % (27)
0.8% (4)
3.5% (17)
1.4% (7)
2.4% (12)
101.3
13.3
31.4
23.9
48.1
37.9
"ICD-10 or DSM-IV.
ICD- 10.
'DSM-IV.
p < .001 for all comparisons of clinic and community sample (continuity adjusted xz).
Table 2
Independent Correlates of a D A W B A Diagnosis in the Community Sample
DAWBA
diagnosis ( N = 52)
No DAWBA
diagnosis ( N = 439)
Odds
ratio
38.5% (20/52)
50.0% (18/36)
25.0 % (6/24)
26.9 % (14/52)
41.6% (15/36)
2.7% (12/438)
7.3 % (23/317)
4.1% (7/177)
1.4% (6/438)
5.7% (18/317)
22.2
12.8
8.1
26.5
11.9
p < .001 for all comparisons of children with and without DAWBA diagnoses (continuity
adjusted x').
R. GOODMAN et al.
650
Emotional disorders
Figure I .
..............
(N=35)
.................
........................
Mean
SDQ
Score
12
65 I
+I
NOdisorder,
high scorers
(N=63)
lo
(Parent-rated)
*-------------.
0
4-6 month
follow-up
Initial survey
Figure 2. DAWBA-identified caseness predicts persistence of problems.
Table 3
DA WBA and Case Note Diagnoses on the Clinic Sample
Case note diagnosis
DAWBA diagnosis
Emotional disorders (ICD-10 or DSM-IV)
Absent
Present
~ ~ ( trend
1 ) = 11.6,p = .001; Kendalls tau b = 0.52
Conduct-oppositionaldisorders (ICD-10 or DSM-IV)
Absent
Present
Absent
Possible
Definite
16
6
11
2
9
10
16
3
3
1
1
15
~ ~ ( for
1 )trend = 9.4, p = .002; Kendalls tau b = 0.47
R. GOODMAN et al.
652
Table 4
EfJicacy of Skip Rules
Disorder
Separation anxiety
Specific phobia
Social phobia
Post-traumatic stress disorder
Obsessive-compulsivedisorder
Generalised anxiety
Depression
ADHD/Hyperkinesis
Oppositional-defiant disorder
Conduct disorder
Proportion who
skip section
Informant
Positive cases
missedawith
skip rules
Communityb
Clinicc
Parent
Child
Parent
Child
Parent
Child
Parent
Child
Parent
Child
Parent
Child
Parent
Child
Parent
Parent
Parent
Child
018
012
2/14
012
019
0/4
015
014
113
013
0114
017
017
015
1/23
1/16
019
117
78 %
77 %
77 %
72 %
79 %
79 %
93 yo
91 %
83 Yo
79 Yo
77 yo
74 Yo
61 %
45 yo
73 %
76 Yo
91 %
71 Yo
31 %
56 %
33 %
37 %
31 %
56 %
77 %
62 %
33 %
50 %
36 %
37 yo
26 %
31 yo
10%
23 yo
28 %
62 Yo
4 % (61142)
76 %
40 %
Average
a Missed cases are those where a positive section would have been skipped had the skip rules
been applied.
bCommunity sample = 223 subjects: all parents interviewed without skip rules; 91 young
people were interviewed without skip rules.
Psychiatric clinic sample = 39 subjects: all parents interviewed without skip rules; 16 young
people were interviewed without skip rules.
Skip Rules
The interviews were administered without using the
skip rules on 262 subjects, 223 of whom were from the
community sample and 39 from the psychiatric clinic
sample. Even when the respondent answered the screening question(s) negatively, the interviewer continued with
the rest of the section. This made it possible to examine
how many sections would have been omitted inappropriately had the skip rules been operating. Table 4 shows
that 4.2 % (95 % confidence interval 0.9-7.5 %) of positive sections would have been missed had the skip rules
been in place. The cost in missed diagnoses can be set
against the extent to which skip rules shorten the
interview. With skip rules in place, 76% of sections for
the community sample could have been omitted after the
screening questions; the corresponding proportion for
clinic cases was 40 % .
additional 20 subjects (4.1 %) who had not been diagnosed by the computer (false negatives). Numbers were
too small to warrant detailed breakdowns of the types of
false positives and negatives, or to permit meaningful
comparisons of the predictive or concurrent validity of
computer-assigned and clinician-assigned diagnoses. The
following three case vignettes provide illustrative examples of subjects whose computer-assigned diagnoses
were changed by the clinical raters.
Subject I : Excluding a computer-assigned diagnosis.
A 13-year-old boy was given a computer diagnosis of a
specific phobia because he had a fear that resulted in
significant distress and avoidance. In his open-ended
description of the fear, he explained that boys from
another school had threatened him on his way home on
several occasions. Since then, he had been afraid of this
gang and had taken a considerably longer route home
every day in order to avoid them. The clinical rater judged
his fear and avoidance to be appropriate responses to a
realistic danger and not a phobia. (Relying on young
respondents to judge whether their own fears are realistic
or exaggerated would clearly be unsatisfactory, since
many young people with phobias lack insight into the
unrealistic nature of their fears.)
Subject 2: Including a diagnosis not made by the
computer. A 7-year-old girl fell just short of the computer algorithms threshold for a diagnosis of ADHD
because the teacher reported that the problems with
restlessness and inattentiveness resulted in very little
impairment in learning and peer relationships at school.
A review of all the evidence showed that the girl had
officially recognised special educational needs as a result
of hyperactivity problems, could not concentrate in class
for morethan 2 minutes at a time even on activities she
enjoyed, and had been offered a trial of medication. The
Discussion
Three lines of evidence support the validity of the
DAWBA. First, the rates of all psychiatric disorders were
substantially higher in the clinic than in the community
sample. Second, in the community sample, subjects with
and without DAWBA diagnoses differed markedly in
external characteristics and prognosis. Third, in the
clinical sample, there was considerable overlap between
DAWBA and case note diagnoses; when the diagnoses
differed, this was nearly always due to the DAWBA
diagnosing comorbid disorders not diagnosed from the
case notes. Further studies will need to clarify whether the
DAWBA over-diagnoses comorbidity or whether British
clinicians tend to under-diagnose comorbidity.
Interviewers and interviewees generally enjoyed the
interviews, particularly when use of the skip rules kept the
interview brief. These skip rules functioned well, allowing
76 % of sections to be skipped in the community sample
at the relatively small cost that 4 % of positive interview
sections were wrongly omitted.
The DAWBA successfully combines the features of
respondent-based and investigator-based measures. It
resembles a respondent-based measure such as the Diagnostic Interview Schedule for Children (DISC; Shaffer et
al., 1996) in that it uses lay interviewers, fixed questions,
and computerised diagnostic algorithms. The two main
differences are that the lay interviewers also transcribe
detailed verbatim responses to open-ended questions, and
that clinical raters use these transcripts to generate
clinically informed diagnoses that sometimes over-rule
the computerised diagnoses. Including a clinical review
only added about 10% to the cost of the survey
(unpublished data). We predict that using clinical rather
than computer diagnoses will generate findings that are
more relevant to service planning. To test this, ongoing
prospective studies of larger samples are comparing the
predictive validity of computer-generated and cliniciangenerated diagnoses in terms of outcome and service use.
Existing investigator-based measures such as the Child
and Adolescent Psychiatric Assessment (CAPA ;Angold
et al., 1995) use clinicians or highly trained nonclinical
interviewers to administer semistructured interviewers to
parents and children. Using flexible questioning, the
interviewer elicits enough information to rate the presence and severity of symptoms and resultant impairments. These interviewer-based ratings can form the basis
653
654
R. GOODMAN et al.
Burns, B. J., Costello, E. J., Angold, A., Tweed, D., Stangl, D.,
Farmer, E. M. Z., & Erkanli, A. (1995). Childrens mental
health service use across service sectors. Health Affairs, 14,
147-159.
Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and
Psychiatry, 38, 58 1-586.
Jensen, P. S., Roper, M., Fisher, P., Piacentini, J., Canino, G.,
Richters, J., Rubio-Stipec, M., Dulkan, M. K., Goodman, S.,
Davies, M., Rae, D., ShaiTer, D., Bird, H. R., Lahey, B. B., &
Schwab-Stone, M. E. (1995). Test-retest reliability of the
Diagnostic Interview Schedule for Children (DISC 2.1).
Archives of General Psychiatry, 52, 61-71.
655
The Virginia twin study of adolescent behavioral development: Influences of age, gender and impairment on rates of
disorder. Archives of General Psychiatry, 54, 801-808.
Tanur, J. M. (1992). Questions about questions: Inquiries into
the cognitive bases of surveys. New York: Russell Sage
Foundation.
Taylor, E., Sandberg, S., Thorley, G., & Giles, S . (1991). The
epidemiology of childhood hyperactivity. Institute of Psychiatry: Maudsley Monographs, 33. Oxford: Oxford University Press.
World Health Organisation. (1994). The ICD-I0 classification
of mental and behavioural disorders: Diagnostic criteria for
research. Geneva: Author.
Manuscript accepted 17 January 2000