Daniel S. S. Fung

International comparisons of behavioral and emotional problems in preschool children: Parents' reports from 24 societies

International comparisons were conducted of preschool childrens behavioral and emotional problems as reported on the Child Behavior Checklist for Ages 1½–5 by parents in 24 societies (N = 19,850). Item ratings were aggregated into scores on syndromes; Diagnostic and Statistical Manual of Mental Disorders–oriented scales; a Stress Problems scale; and Internalizing, Externalizing, and Total Problems scales. Effect sizes for scale score differences among the 24 societies ranged from small to medium (3–12%). Although societies differed greatly in language, culture, and other characteristics, Total Problems scores for 18 of the 24 societies were within 7.1 points of the omnicultural mean of 33.3 (on a scale of 0–198). Gender and age differences, as well as gender and age interactions with society, were all very small (effect sizes < 1%). Across all pairs of societies, correlations between mean item ratings averaged .78, and correlations between internal consistency alphas for the scales averaged .92, indicating that the rank orders of mean item ratings and internal consistencies of scales were very similar across diverse societies.

International Epidemiology of Child and Adolescent Psychopathology II: Integration and Applications of Dimensional Findings From 44 Societies

OBJECTIVE To build on Achenbach, Rescorla, and Ivanova (2012) by (a) reporting new international findings for parent, teacher, and self-ratings on the Child Behavior Checklist, Youth Self-Report, and Teachers Report Form; (b) testing the fit of syndrome models to new data from 17 societies, including previously underrepresented regions; (c) testing effects of society, gender, and age in 44 societies by integrating new and previous data; (d) testing cross-society correlations between mean item ratings; (e) describing the construction of multisociety norms; (f) illustrating clinical applications. METHOD Confirmatory factor analyses (CFAs) of parent, teacher, and self-ratings, performed separately for each society; tests of societal, gender, and age effects on dimensional syndrome scales, DSM-oriented scales, Internalizing, Externalizing, and Total Problems scales; tests of agreement between low, medium, and high ratings of problem items across societies. RESULTS CFAs supported the tested syndrome models in all societies according to the primary fit index (Root Mean Square Error of Approximation [RMSEA]), but less consistently according to other indices; effect sizes were small-to-medium for societal differences in scale scores, but very small for gender, age, and interactions with society; items received similarly low, medium, or high ratings in different societies; problem scores from 44 societies fit three sets of multisociety norms. CONCLUSIONS Statistically derived syndrome models fit parent, teacher, and self-ratings when tested individually in all 44 societies according to RMSEAs (but less consistently according to other indices). Small to medium differences in scale scores among societies supported the use of low-, medium-, and high-scoring norms in clinical assessment of individual children.

A brain-computer interface based attention training program for treating attention deficit hyperactivity disorder.

Attention deficit hyperactivity disorder (ADHD) symptoms can be difficult to treat. We previously reported that a 20-session brain-computer interface (BCI) attention training programme improved ADHD symptoms. Here, we investigated a new more intensive BCI-based attention training game system on 20 unmedicated ADHD children (16 males, 4 females) with significant inattentive symptoms (combined and inattentive ADHD subtypes). This new system monitored attention through a head band with dry EEG sensors, which was used to drive a feed forward game. The system was calibrated for each user by measuring the EEG parameters during a Stroop task. Treatment consisted of an 8-week training comprising 24 sessions followed by 3 once-monthly booster training sessions. Following intervention, both parent-rated inattentive and hyperactive-impulsive symptoms on the ADHD Rating Scale showed significant improvement. At week 8, the mean improvement was −4.6 (5.9) and −4.7 (5.6) respectively for inattentive symptoms and hyperactive-impulsive symptoms (both p<0.01). Cohen’s d effect size for inattentive symptoms was large at 0.78 at week 8 and 0.84 at week 24 (post-boosters). Further analysis showed that the change in the EEG based BCI ADHD severity measure correlated with the change ADHD Rating Scale scores. The BCI-based attention training game system is a potential new treatment for ADHD. Trial Registration ClinicalTrials.gov NCT01344044

Identification of Autism Spectrum Disorders Using the Child Behavior Checklist in Singapore

We tested the ability of the 2001 CBCL syndromes to discriminate among 86 children with Autism Spectrum Disorder (ASD), 117 children with Attention Deficit Hyperactivity Disorder—Inattentive type, 426 children with Attention Deficit Hyperactivity Disorder—Hyperactive-Impulsive or Combined type, 200 clinically referred children who did not receive a diagnosis, and 436 typically-developing children in a community sample. The Withdrawn/Depressed, Social Problems, and Thought Problems syndromes significantly discriminated the ASD group from the four other groups. An ASD scale, constructed from nine CBCL items, demonstrated moderate to high sensitivity (68 to 78%) and specificity (73 to 92%). Consistent with previous research, findings from this study provide strong support for the CBCL as a screening tool for ASD.

Parent–Teacher Agreement on Children's Problems in 21 Societies

Parent–teacher cross-informant agreement, although usually modest, may provide important clinical information. Using data for 27,962 children from 21 societies, we asked the following: (a) Do parents report more problems than teachers, and does this vary by society, age, gender, or type of problem? (b) Does parent–teacher agreement vary across different problem scales or across societies? (c) How well do parents and teachers in different societies agree on problem item ratings? (d) How much do parent–teacher dyads in different societies vary in within-dyad agreement on problem items? (e) How well do parents and teachers in 21 societies agree on whether the childs problem level exceeds a deviance threshold? We used five methods to test agreement for Child Behavior Checklist (CBCL) and Teachers Report Form (TRF) ratings. CBCL scores were higher than TRF scores on most scales, but the informant differences varied in magnitude across the societies studied. Cross-informant correlations for problem scale scores varied moderately across societies studied and were significantly higher for Externalizing than Internalizing problems. Parents and teachers tended to rate the same items as low, medium, or high, but within-dyad item agreement varied widely in every society studied. In all societies studied, both parental noncorroboration of teacher-reported deviance and teacher noncorroboration of parent-reported deviance were common. Our findings underscore the importance of obtaining information from parents and teachers when evaluating and treating children, highlight the need to use multiple methods of quantifying cross-informant agreement, and provide comprehensive baselines for patterns of parent–teacher agreement across 21 societies.

Depression and anxiety in Singaporean high-risk pregnancies - prevalence and screening

OBJECTIVE Data on psychiatric morbidity in high-risk pregnant Singaporean women are limited. This study aimed to establish the prevalence of antenatal depression and anxiety in high-risk pregnancies, compare the prevalence of antenatal depression in high-risk pregnancies vs. pregnancies of unspecified obstetric risk and examine the Edinburgh Postnatal Depression Scale (EPDS) and State Trait Anxiety Inventory (STAI) as screening tools for these disorders. METHOD Two hundred high-risk pregnant inpatients at a national public maternity hospital were included. Three psychometric assessment tools were used to evaluate all participants: the diagnostic Mini International Neuropsychiatric Interview and the screening EPDS and STAI. RESULTS Rates of major depression, minor depression, anxiety disorder (agoraphobia, generalized anxiety disorder, panic disorder), and comorbid depression and anxiety were 11%, 7%, 12.5% and 5%, respectively. Major depression was more prevalent in high-risk pregnancies than in the historical cohort of unspecified obstetric risk (11% versus 4.3%). EPDS (cutoff 8/9) screens well for depression and anxiety in high-risk pregnancies (area under the receiver operating characteristic curve=0.82-0.87). CONCLUSION Antenatal depression and anxiety are highly prevalent in a sample of high-risk pregnant Singaporean women. EPDS performs well in screening for depression and anxiety in high-risk pregnant women, with further psychiatric assessment recommended for women with score ≥ 9.

Examining the criterion validity of CBCL and TRF problem scales and items in a large Singapore sample.

This study examined the criterion validity of the Child Behavior Checklist (CBCL) and Teacher’s Report Form (TRF) problem scales and items in demographically-matched Singapore samples of referred and non-referred children (840 in each sample for the CBCL and 447 in each sample for the TRF). Internal consistency estimates for both the CBCL and TRF scales were good. Almost all CBCL and TRF problem scales and items significantly discriminated between referred and non-referred children, with referred children scoring higher, as expected. The largest referral status effects were on attention problems scales and their associated items, with the TRF having larger effects than the CBCL. Effect sizes for demographic variables such as age, gender, ethnicity and SES were much smaller than effect sizes for referral status, across both the CBCL and TRF forms and at both the scale and item levels. These findings suggest that teachers can be effective partners in identifying children who need mental health services and those who do not.

Anxiety symptoms in young people with autism spectrum disorder attending special schools: Associations with gender, adaptive functioning and autism symptomatology

Anxiety-related problems are among the most frequently reported mental health difficulties in autism spectrum disorder. As most research has focused on clinical samples or high-functioning children with autism spectrum disorder, less is known about the factors associated with anxiety in community samples across the ability range. This cross-sectional study examined the association of gender, age, adaptive functioning and autism symptom severity with different caregiver-reported anxiety symptoms. Participants were caregivers of 241 children (6–18 years old) with autism spectrum disorder attending special schools in Singapore. Measures included the Spence Children’s Anxiety Scale and assessments of overall emotional, behavioural and adaptive functioning. Caregivers reported more anxiety symptoms in total, but fewer social anxiety symptoms, than Spence Children’s Anxiety Scale Australian/Dutch norms. There were no gender differences. Variance in total anxiety scores was best explained by severity of repetitive speech/stereotyped behaviour symptoms, followed by adaptive functioning. Severity of repetitive speech/behaviour symptoms was a significant predictor of separation anxiety, generalized anxiety, panic/agoraphobia and obsessive–compulsive subscale symptoms, but not of social phobia and physical injury fears. Adaptive functioning and chronological age predicted social phobia and generalized anxiety symptoms only. Severity of social/communication autism symptoms did not explain any anxiety symptoms, when the other variables were controlled for. Findings are discussed in relation to the existing literature. Limitations and possible implications for prevention, assessment and intervention are also discussed.

Gender Differences in Life Stressors Associated with Child and Adolescent Suicides in Singapore from 1995 to 2003

Aims: This study explored gender differences in life stressors of children and adolescents who died by suicide. Three main classes of life stressors have been identified by previous research to be significant risk factors for suicide in children and adolescents: interpersonal/relationship problems, family problems, and academic/school problems. Methods: The sample consisted of 156 (89 males and 67 females) completed child and adolescent suicides in Singapore from 1995 to 2003. The age of these individuals ranged from 10 to 19 years with a mean age of 16.49 (SD = 2.59). Results: Significantly more females were found to have had interpersonal/relationship problems as recent life stressors compared with males. No gender differences were found for the other two life stressors, family problems and academic/school problems. In addition, among the three life stressors studied, only interpersonal/relationship problems emerged as a significant predictor of female child and adolescent suicide. Conclusions: Consistent with previous research literature, these findings contribute to a growing literature documenting the relatively larger impact of relational life stressors on child and adolescent female suicidality. Implications for suicide intervention and prevention, especially among young females, were discussed.

Screening for major and minor depression in a multiethnic sample of Asian primary care patients: A comparison of the nine-item Patient Health Questionnaire (PHQ-9) and the 16-item Quick Inventory of Depressive Symptomatology – Self-Report (QIDS-SR16)

Depression is common, disabling, and the single most important factor leading to suicide, yet it is underdiagnosed in busy primary care settings. A key challenge facing primary care clinicians in Asia is the selection of instruments to facilitate depression screening. Although the nine‐item Patient Health Questionnaire (PHQ‐9) and 16‐item Quick Inventory of Depressive Symptomatology – Self‐Report (QIDS‐SR16) are used internationally, they have not been directly compared or widely validated in Asian primary care populations. This study aimed to validate the PHQ‐9 and QIDS‐SR16 against a structured interview diagnosis of Diagnostic and Statistical Manual, 4th Edition, depression based on the Mini‐International Neuropsychiatric Interview in a multiethnic Asian sample.