Sushila Russell

The psychometric properties of Beck Depression Inventory for adolescent depression in a primary-care paediatric setting in India

BackgroundThere is increasing interest in identifying adolescents with depression in primary care settings by paediatricians in India. This article studied the diagnostic accuracy, reliability and validity of Beck Depression Inventory (BDI) while used by paediatricians in a primary care setting in India.Methods181 adolescents attending 3 schools were administered a back translated Tamil version of BDI by a paediatrician to evaluate its psychometric properties along with Childrens Depression Rating Scale (CDRS-R) for convergent validity. Clinical diagnosis of depressive disorders, for reference standard, was based on ICD-10 interview by an independent psychiatrist who also administered the Impact of Event Scale (IES) for divergent validity. Appropriate analyses for validity and diagnostic accuracy both at the item and scale levels were conducted.ResultsA cut-off score of ≥ 5 (Sn = 90.9%, Sp = 17.6 %) for screening and cut-off score of ≥ 22 (Sn = 27.3%, Sp = 90%) for diagnostic utility is suggested. The 4 week test – retest reliability was good (r = 0.82). In addition to the adequate face and content validity, BDI has very good internal consistency (α = 0.96), high convergent validity with CDRS-R (r = 0.72; P = 0.001), and high discriminant validity with IES (r = 0.26; P = 0.23). There was a moderate concordance rate with the reference standard (54.5%) in identifying depression among the adolescents. Factor analysis replicated the 2-factor structure explaining 30.5 % of variance.ConclusionThe BDI proved to be a psychometrically sound measure for use by paediatricians in a primary care setting in India. The possibility of screening for depressive disorders through the use of BDI may be helpful in identifying probable cases of the disorder among adolescents.

Diagnostic accuracy, reliability and validity of Childhood Autism Rating Scale in India

BackgroundSince there is no established measure for autism in India, we evaluated the diagnostic accuracy, reliability and validity of Childhood Autism Rating Scale (CARS).MethodsChildren and adolescents suspected of having autism were identified from the unit’s database. Scale and item level scores of CARS were collected and analyzed. Sensitivity, specificity, likelihood ratios and predictive values for various CARS cut-off scores were calculated. Test-retest reliability and inter-rater reliability of CARS were examined. The dichotomized CARS score was correlated with the ICD-10 clinical diagnosis of autism to establish the criterion validity of CARS as a measure of autism. Convergent and divergent validity was calculated. The factor structure of CARS was demonstrated by principal components analysis.ResultsA CARS score of ≥33 (sensitivity = 81.4%, specificity = 78.6%; area under the curve = 81%) was suggested for diagnostic use in Indian populations. The inter-rater reliability (ICC=0.74) and test-retest reliability (ICC=0.81) for CARS were good. Besides the adequate face and content validity, CARS demonstrated good internal consistency (Cronbach’s α=0.79) and item-total correlation. There was moderate convergent validity with Binet-Kamat Test of Intelligence or Gessell’s Developmental Schedule (r=0.42; P=0.01), divergent validity (r=−0.18; P=0.4) with ADD-H Comprehensive Teacher Rating Scale, and high concordance rate with the reference standard, ICD-10 diagnosis (82.52%; Cohen’s κ=0.40, P=0.001) in classifying autism. A 5-factor structure explained 65.34% of variance.ConclusionThe CARS has strong psychometric properties and is now available for clinical and research work in India.

Family intervention and acquisition of adaptive behaviour among intellectually disabled children

A trial was designed to evaluate the role of enhanced parental attitude towards management of intellectual disability in the acquisition of adaptive behaviour. Fifty-seven children with intellectual disability and their parents were randomly assigned to 12 weeks of either multimodal adaptive behaviour training plus interactive group psycho-education (intervention group); or multimodal adaptive behaviour training plus didactic lectures (control group). Blinded raters were involved. Completers’ and intention-to-treat analyses were conducted. In the intention-to-treat sample, 22 of 29 children in the intervention group compared with four of 28 children in the control group showed a significant improvement in the acquisition of adaptive behaviour. The minimum additive efficacy provided by the enhanced parental attitude was 80 percent. Meaningful clinical benefits on various measures were found for the intervention group after training. Parental attitude intervention should be included in adaptive behaviour training for children with intellectual disability, as enhanced parental attitude has short-term positive effects.

Psychometric properties of Tamil version of Impact of Event Scale for adolescents

Objective: This study validates the Tamil version of Impact of Event Scale among adolescents. Method: IES was translated into Tamil and 100 adolescents attending an adolescent clinic who had been exposed to diverse traumatic events completed the Impact of Event Scale along with the Child Behaviour Checklist. Appropriate analyses both at the item and scale levels were conducted. Results: In addition to adequate face and content validity, the scale has satisfactory internal consistency (α from 0.77 to 0.90), moderate convergent validity with CBCL‐PTSD scale (r from 0.22 to 0.29), and high discriminant validity with PTSD‐thought problem subscale (r = 0.01–0.10). Factor analysis replicated the two‐factor structure, avoidance factor (five items) and intrusion factor (three items), explaining 68.4% of variance. A threshold IES score of 17 was associated with 93% sensitivity and 85% specificity. Conclusions: The Tamil IES for adolescents has satisfactory psychometric properties and should be useful in internatio...

CDC Kerala 9: Effectiveness of Low Intensity Home Based Early Intervention for Autism Spectrum Disorder in India

ObjectiveTo validate effectiveness of low intensity, home based early intervention (EI) models in autism for countries with low disability resources.MethodsFifty-two toddlers and young children were assessed before and after intervention with Childhood Autism Rating Scale, Vineland Social Maturity Scale, and Receptive-Expressive Emergent Language Scale. Developmental and speech therapists helped mothers assemble low-cost training kits based on the developmental age of the child, gave initial training in the basic behavioral technique to address the three autism symptom clusters at home. Follow-up support was given either on a weekly, fortnightly or monthly basis. Most of the children were also placed in play-schools. Data was analyzed using appropriate bivariate and multivariate techniques.ResultsThere was statistical and clinical amelioration in the severity of autism, with acquisition of social skills and language skills (all P = 0.001) after intervention in children with mild to severe autism. Gender showed a trend in becoming a significant predictor for intervention response.ConclusionsLow-intensity, home-based EI can be effectively used in situations where there is paucity of disability resources in countries like India, especially in primary-care and community settings.

Psychopathology and functional impairment among patients attending an adolescent health clinic: Implications for healthcare model reform

BackgroundIn developing countries, primary health care facilities, such as adolescent health clinics, are frequently the first contact for an adolescent with a health professional for a myriad of health problems including mental health issues. Psychopathology is prevalent among adolescents, and causes significant educational, occupational and social impairment. The presence of psychopathology with impairment requires the development of treatment models to address both of these components. We studied the psychopathology and associated impairment in patients at an adolescent health clinic as an indicator for healthcare model reform.MethodsPsychopathology and functional impairment were assessed in 100 patients at an adolescent health clinic in the city of Chennai, Southern India. The patients had initially visited the clinic for various medical disorders. Adolescents were diagnostically classified for psychopathology using the Child Behaviour Checklist (CBCL) and the International Classification of Disease: 10th Edition (ICD-10). Functional impairment was assessed with the Child Global Assessment Scale (CGAS). Data were analysed using bivariate and multivariate methods.ResultsEight percent had a diagnosable psychopathology, and they also satisfied at least one ICD-10 diagnosis. Adolescents screened had significant impairment as indicated by low CGAS scores, whether or not they presented with psychopathology. Adolescents with psychopathology were more functionally impaired both in the bivariate (Z = -3.1; P = 0.002) and multivariate analyses (β(SE) = 1.09(0.3), t = 3.9, 95% confidence interval = 0.5, 1.6; P = 0.001). Impairment in adolescents without psychopathology is primarily attributed to the medical disorders they presented with.ConclusionPatients attending adolescent health clinics should be screened for psychopathology and functional impairment. Documented psychopathology and impairment necessitates the use of a combined treatment model to address the short and long-term problems these adolescents face.

Emerging trends in accepting the term intellectual disability in the world disability literature

English terminology thrives on words; words that are coined arbitrarily and often used idiosyncratically across time and space. In the past, some of the terms once used to describe individuals with compromised intellectual ability were not only acceptable (idiots: private person in Greek, imbecillis: weak and frail in Latin) but even honourable (cretins: Christian in Swiss-French), but are now used only as insults. As many of these old labels fade new ones evolve only to demonstrate that they themselves have a significantly short shelf-life. Whereas this editorial will argue that the term intellectual disability has universal consensus because of the manifold rationale discussed here. First, the debate as to whether the terminology or attitude should change in this context is an unsettled dispute. Terminologies are not neutral; they display the view of those who use it and indoctrinate those who hear it. This idea comes from an assumption that language is thought, and therefore when those with the disability have objected to these terms as reflections of the thoughts of others about them, such terms have to be discarded (Reid, 1997). Those who support a change in attitude, challenge that terms need not be thoughts, as we are often unable to translate some of our own thoughts into words. We solve problems manipulating mental images without using language and invent words for new ideas for which no words existed before, suggesting that it is our thoughts that contaminate our euphemisms, not the euphemisms that disinfect our thoughts (Crichton, 1997). In this polarized context the change in terminology to intellectual disability might be important in changing existing attitudes, and therefore may be widely appreciated by the professional community, e d i to r i a l

Priority Mental Health Disorders of Children and Adolescents in Primary-care Pediatric Setting in India 1: Developing a Child and Adolescent Mental Health Policy, Program, and Service Model

India has a huge child and adolescent population. Psychiatric disorders are widely prevalent and the mental health needs of these children are well recognized. Nonetheless, there are no country-centric and child specific mental health policies, plans or programs. There is also a significant lack of human resources for child and adolescent mental health in India. This combination of factors makes the primary care a critical setting for the early identification, treatment, consultation and referral of children and adolescents with mental health and developmental needs. Even though the importance of primary care as a system for addressing the mental health care has been recognized for decades, its potential requires further development in India as the Child and Adolescent Mental Health Services (CAMHS) emerge and evolve. A country and child specific mental health policy, plan and program needs to be formulated as well an integrated, multi-tier CAMHS with a focus on the primary-care physicians as care providers for this population has to be developed.

Validation of the children's depression rating scale- revised for adolescents in primary-care pediatric use in India

BACKGROUND Adolescent depression needs to be identified and treated in the primary care settings. There is no clinician-rated measure validated in India for identifying depression among adolescents. AIM We studied the diagnostic accuracy, reliability, and validity of Childrens Depression Rating Scale - Revised (CDRS-R) for primary care pediatrics. SETTING AND DESIGN Prospective study in three schools in Southern India. MATERIALS AND METHODS Adolescents recruited were administered the CDRS-R by a pediatrician and clinical psychologist along with Beck Depression Inventory (BDI) for convergent validity. Impact of Event Scale (IES) for divergent validity and the ICD-10 clinical diagnosis of depressive disorders using modified Kiddie-SADS-Present and Lifetime Version (K-SADS-PL) interview as reference standard were administered by a psychiatrist independently. Appropriate statistical analyses for diagnostic accuracy, reliability, and validity were done. RESULTS A cut-off score of 30 (sensitivity = 83%, specificity = 84%; AUC in ROC = 87%) in CDRS-R is suggested for diagnosing depression. The inter-rater reliability (r = 0.73) and test-retest reliability (r = 0.98) was good. In addition to the adequate face and content validity, CDRS-R had good internal consistency (α = 0.76), high convergent (r = 0.71; P = 0.001), and divergent validity (r = 0.28; P = 0.20). There was moderate concordance with the reference standard of ICD-10 diagnosis (45.5%) in identifying depression and CDRS-R discriminated 80% of the other psychiatric morbidity. The six-factor structure explained 60.6% of variance. CONCLUSION The CDRS-R showed strong psychometric properties and is now available for use in the primary-care pediatric practice in India.

Psychometrics and utility of Psycho-Educational Profile–Revised as a developmental quotient measure among children with the dual disability of intellectual disability and autism

There is no agreement about the measure to quantify the intellectual/developmental level in children with the dual disability of intellectual disability and autism. Therefore, we studied the psychometric properties and utility of Psycho-Educational Profile–Revised (PEP-R) as a developmental test in this population. We identified 116 children with dual disability from the day care and inpatient database of a specialised Autism Clinic. Scale and domain level scores of PEP-R were collected and analyzed. We examined the internal consistency, domain-total correlation of PEP-R and concurrent validity of PEP-R against Gesell’s Developmental Schedule, inter-rater and test–retest reliability and utility of PEP-R among children with dual disability in different ages, functional level and severity of autism. Besides the adequate face and content validity, PEP-R demonstrates a good internal consistency (Cronbach’s α ranging from 0.91 to 0.93) and domain-total correlation (ranging from 0.75 to 0.90). The inter-rater reliability (intraclass correlation coefficient, ICC = 0.96) and test–retest reliability (ICC = 0.87) for PEP-R is good. There is moderate-to-high concurrent validity with GDS (r ranging from 0.61 to 0.82; all Ps = 0.001). The utility of PEP-R as a developmental measure was good with infants, toddlers, pre-school and primary school children. The ability of PEP-R to measure the developmental age was good, irrespective of the severity of autism but was better with high-functioning children. The PEP-R as an intellectual/developmental test has strong psychometric properties in children with dual disability. It could be used in children with different age groups and severity of autism. PEP-R should be used with caution as a developmental test in children with dual disability who are low functioning.