Validation of the Preschool and Early Childhood Functional Assessment Scale (PECFAS)

Overview of Ten Child Mental Health Clinical Outcome Measures: Testing of Psychometric Properties with Diverse Client Populations in the U.S

While many standardized assessment measures exist to track child mental health treatment outcomes, the degree to which such tools have been adequately tested for reliability and validity across race, ethnicity, and class is uneven. This paper examines the corpus of published tests of psychometric properties for the ten standardized measures used in U.S. child outpatient care, with focus on breadth of testing across these domains. Our goal is to assist care providers, researchers, and legislators in understanding how cultural mismatch impacts measurement accuracy and how to select tools appropriate to the characteristics of their client populations. We also highlight avenues of needed research for measures that are in common use. The list of measures was compiled from (1) U.S. state Department of Mental Health websites; (2) a survey of California county behavioral health agency directors; and (3) exploratory literature scans of published research. Ten measures met inclusion criteria; for each one a systematic review of psychometrics literature was conducted. Diversity of participant research samples was examined as well as differences in reliability and validity by gender, race or ethnicity, and socio-economic class. All measures showed adequate reliability and validity, however half lacked diverse testing across all three domains and all lacked testing with Asian American/Pacific Islander and Native American children. ASEBA, PSC, and SDQ had the broadest testing.

A Brief Early Childhood Screening Tool for Psychopathology Risk in Primary Care: The Moderating Role of Poverty

OBJECTIVES

To evaluate the Preschool Feeling Checklist (PFC) utility for predicting later mental disorders and functioning for children and assess whether the PFC's predictive utility differs as a function of childhood poverty.

STUDY DESIGN

We analyzed data from a prospective longitudinal study of preschoolers in St Louis. Preschoolers (N = 287) were recruited from primary care sites and were assessed annually for 10-15 years. The PFC screened for depressive symptoms. Later age-appropriate psychiatric diagnostic interviews were used to derive Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnoses. Regression and moderation analyses, and multilevel modeling were used to test the association between the PFC and later outcomes, and whether this relationship was moderated by income-to-needs.

RESULTS

The PFC predicted major depressive disorder (OR 1.13, P < .001), attention deficit hyperactivity disorder (OR 1.16, P < .001), and mania (OR 1.18, P < .05) in adolescence and early adulthood. Income-to-needs was a moderator in the predictive pathway between the PFC and later major depressive disorder (OR 1.10, P < .05) and mania (OR 1.19, P < .001) with the measure less predictive for children living in poverty. The PFC predicted worse functioning by the final assessment (b = 1.71, SE = 0.51, P = .001).

CONCLUSIONS

The PFC served as an indicator of risk for later attention deficit hyperactivity disorder and impairment in all children. It has predictive utility for later mood disorders only in children living above the poverty line. Predicting depression in children living below the poverty line may require consideration of risk factors not covered by the PFC.

How an Electronic Medical Record System Facilitates and Demonstrates Effective Psychosocial Screening in Pediatric Primary Care

Using questionnaires, administrative claims, and chart review data, the current study explored the impact of using an electronic medical record system to administer, score, and store the Pediatric Symptom Checklist (PSC-17) during annual pediatric well-child visits. Within a sample of 1773 Medicaid-insured outpatients, the electronic system demonstrated that 90.5% of cases completed a PSC-17 screen electronically, billing codes indicating a screen was administered agreed with the existence of a questionnaire in the chart in 98.8% of cases, the classification of risk based on PSC-17 scores agreed with the classification of risk based on the Current Procedural Terminology code modifiers in 72.9% of cases, and 90.0% of clinicians' progress notes mentioned PSC-17 score in treatment planning. Using an electronic approach to psychosocial screening in pediatrics facilitated the use of screening information gathered during the clinical visit and allowed for enhanced tracking of outcomes and quality monitoring.

Excitability and irritability in preschoolers predicts later psychopathology: The importance of positive and negative emotion dysregulation

Emotion dysregulation is a risk factor for the development of a variety of psychopathologic outcomes. In children, irritability, or dysregulated negative affect, has been the primary focus, as it predicts later negative outcomes even in very young children. However, dysregulation of positive emotion is increasingly recognized as a contributor to psychopathology. Here we used an exploratory factor analysis and defined four factors of emotion dysregulation: irritability, excitability, sadness, and anhedonia, in the preschool-age psychiatric assessment collected in a sample of 302 children ages 3-5 years enriched for early onset depression. The irritability and excitability factor scores defined in preschoolers predicted later diagnosis of mood and externalizing disorders when controlling for other factor scores, social adversity, maternal history of mood disorders, and externalizing diagnoses at baseline. The preschool excitability factor score predicted emotion lability in late childhood and early adolescence when controlling for other factor scores, social adversity, and maternal history. Both excitability and irritability factor scores in preschoolers predicted global functioning into the teen years and early adolescence, respectively. These findings underscore the importance of positive, as well as negative, affect dysregulation as early as the preschool years in predicting later psychopathology, which deserves both further study and clinical consideration.

Maternal drug abuse history, maltreatment, and functioning in a clinical sample of urban children

OBJECTIVE

This study examined the association between maternal drug abuse history, maltreatment exposure, and functioning, in a clinical sample of young children seeking therapy for maltreatment.

METHODS

Data were collected on 91 children, mean age 5.3years (SD 1.0). The Preschool and Early Childhood Functional Assessment Scales (PECFAS) was used to measure functional impairment. A child maltreatment exposure (CME) score was developed based on maltreatment history. Data on maternal risk factors including maternal drug abuse (MDA) were obtained. Data were analyzed using descriptive statistics and regression modeling.

RESULTS

Approximately half (47.3%) of the children had a history of MDA. MDA history was associated with increased odds of neglect (OR=5.6, 95% CI=2.2-14.6) and abandonment (OR=3.3, 95% CI=1.3-8.3), and decreased odds of sexual abuse (OR=0.35, 95% CI=0.2-0.8). There were no statistically significant differences in CME scores for children with MDA history when compared to children without MDA history. Children with MDA history had an increased mean functional impairment score (mean 15 points; 95% CI=1.3-29.2) compared to children without MDA history. Following adjustment for maltreatment, no difference in impairment score was found.

CONCLUSION

Although MDA history was associated with higher odds of neglect and abandonment, it was not associated with total CME or functional impairment. Adverse socio-environmental experiences associated with urban environments may confer a high risk of CME and functional impairment, irrespective of MDA history.

PRACTICE IMPLICATIONS

In addition to maternal drug abuse, clinicians working with children need to identify other factors which could place the child at added risk for maltreatment. Further research is needed to better understand the role of adverse socio-environmental experiences on maltreatment and functional impairment in children. This study highlights the need for a multi-disciplinary approach to prevention and intervention programs needed to diminish adverse socio-environmental conditions prevalent in urban environments.

A novel early intervention for preschool depression: findings from a pilot randomized controlled trial

BACKGROUND

Validation for depression in preschool children has been established; however, to date no empirical investigations of interventions for the early onset disorder have been conducted. Based on this and the modest efficacy of available treatments for childhood depression, the need for novel early interventions has been emphasized. Large effect sizes (ES) for preschool psychotherapies for several Axis I disorders suggest that earlier intervention in depression may also be promising. Therefore, a novel form of treatment for preschool depression, Parent-Child Interaction Therapy Emotion Development (PCIT-ED) was developed and tested.

METHODS

A preliminary randomized controlled trial (RCT) was conducted comparing PCIT-ED to psycho-education in depressed 3- to 7-year-olds and their caregivers. A total of 54 patients met symptom criteria for DSM-IV major depressive disorder and were randomized, 19 patients completed the active treatment (n = 8 dropouts) and 10 completed psycho-education (n = 17 dropouts).

RESULTS

Both groups showed significant improvement in several domains, with PCIT-ED showing significance in a greater number of domains. An intent-to-treat analysis suggested that PCIT-ED was significantly more effective than psycho-education on executive functioning (p = .011, ES = 0.12) and emotion recognition skills (p = .002, ES = 0.83).

CONCLUSIONS

The RCT proved feasible and suggests an individual control condition should be used in future trials to minimize differential dropout. These pilot data, although limited by power, suggest that PCIT-ED may be a promising early intervention for depression. Larger scale randomized controlled trials of PCIT-ED for depressed preschoolers are now warranted.

Parent-child interaction therapy emotion development: a novel treatment for depression in preschool children

BACKGROUND

Psychotherapies with known efficacy in adolescent depression have been adapted for prepubertal children; however, none have been empirically validated for use with depressed very young children. Due to the centrality of the parent-child relationship to the emotional well being of the young child, with caregiver support shown to mediate the risk for depression severity, we created an Emotional Development (ED) module to address emotion development impairments identified in preschool onset depression. The new module was integrated with an established intervention for preschool disruptive disorders, Parent Child Interaction Therapy (PCIT). Preliminary findings of an open trial of this novel intervention, PCIT-ED, with depressed preschool children are reported.

METHODS

PCIT was adapted for the treatment of preschool depression by incorporating a novel emotional development module, focused on teaching the parent to facilitate the child's emotional development and enhance emotion regulation. Eight parent-child dyads with depressed preschoolers participated in 14 sessions of the treatment. Depression severity, internalizing and externalizing symptoms, functional impairment, and emotion recognition/discrimination were measured pre- and posttreatment.

RESULTS

Depression severity scores significantly decreased with a large effect size (1.28). Internalizing and externalizing symptoms as well as functional impairment were also significantly decreased pre- to posttreatment.

CONCLUSIONS

PCIT-ED seems to be a promising treatment for preschoolers with depression, and the large effect sizes observed in this open trial suggest early intervention may provide a window of opportunity for more effective treatment. A randomized controlled trial of PCIT-ED in preschool depression is currently underway.

The clinical significance of preschool depression: impairment in functioning and clinical markers of the disorder

OBJECTIVE

While much is now known about depression during school age and adolescence, whether clinical depression can onset even earlier in development during the preschool period remains under explored. The earliest possible identification of depression may be important for the design of prevention and early developmental intervention programs. This study investigated functional impairment associated with depression, symptoms that served as the best markers of depression vs. other disorders, as well as depression severity between two depressed sub-groups and other diagnostic comparison groups.

METHOD

Three hundred and five preschoolers between the ages of 3.0 and 6.0 and their primary caregivers were recruited using a depression screening checklist distributed at community sites. The Preschool Age Psychiatric Assessment (PAPA) was used to derive psychiatric diagnoses in the study sample. Multivariate analyses of covariance were used to investigate the effects of depression on independent measures of functional impairment while controlling for the effects of co-morbidities.

RESULTS

Functional impairment specifically associated with depression was found in multiple domains and contexts, however depressed preschoolers were not developmentally delayed. The symptoms of guilt and extreme fatigue were found to be highly specific for preschool depression. A statistically significant hierarchy of depression severity was found between diagnostic comparison groups, in the expected direction with the highest in a melancholic subgroup.

CONCLUSIONS

Validation for preschool depression with associated functional impairment across contexts was found in preschool children. These findings replicate and extend earlier evidence for validity of MDD diagnosed in the preschool period and highlight the need for clinical attention. The finding that these depressed and impaired preschoolers were not yet developmentally delayed may have important public health significant significance as it suggests a possible window of opportunity for early intervention. Study findings were limited by reliance on parent and teacher informants and a cross-sectional view.

Depression and social functioning in preschool children with chronic medical conditions

OBJECTIVE

To investigate the relations among depressive symptoms, social behavior, and chronic medical illness in preschool children.

STUDY DESIGN

Caregivers of 273 preschool children (3.0-5.2 years of age) completed questionnaires about preschoolers' physical health, depressive symptoms, and social behavior. Interviewers determined ratings for preschoolers' impairment in social and behavioral functioning. Analyses examined the relationships among chronic medical conditions, depressive symptoms, peer acceptance/rejection, and social behavior.

RESULTS

Chronic illness was significantly associated with early-onset depressive symptoms and impairment in several social functioning domains, even after accounting for socioeconomic status. Regression analyses demonstrated that the number of health conditions predicted higher depression scores, frequency of asocial behaviors, and impairment in daycare role cooperation and behavior toward others. Preschoolers with at least 1 medical condition experienced a greater frequency of peer rejection and bullying compared with healthy peers. Depressive symptoms mediated the relationship between illness and asocial behavior.

CONCLUSIONS

There is a need for greater attention to depression and difficulties in social functioning in preschool children with chronic illness. Because of the potential impact on later developmental and mental health outcomes, primary care physicians should be attentive now to depressive symptoms in chronically ill preschoolers.

Assessing child and youth well-being: implications for child welfare practice

The measurement of child well-being has become increasingly important in child welfare practice in the past ten years with the federal emphasis on measuring positive outcomes for children and families. Practical and methodological barriers to evaluating well-being exist alongside positive developments in the field. This article reviews the research literature related to child and youth well-being, providing a context for the discussion of measurement issues in child welfare settings. Based on a structured review of the literature, the article discusses instruments that appear to be most appropriate for use in a child welfare setting. Instruments are presented within stages of development, including (1) Infancy and Early Childhood, (2) Middle Childhood, and (3) Adolescence. Implications for the design and use of child well-being instruments in child welfare practice are discussed.

Psychotropic prescriptions in a sample including both healthy and mood and disruptive disordered preschoolers: relationships to diagnosis, impairment, prescriber type, and assessment methods

OBJECTIVE

Epidemiological data has shown that psychotropic medications are being prescribed to preschoolers at increasing rates. The diagnostic context and functional impairment of these preschoolers remains unknown. This investigation aimed to address these questions in a sample of preschoolers who were either without symptoms (healthy) or with mood and disruptive disorders by assessing them using a structured diagnostic interview and measure of impairment.

METHOD

Preschoolers aged 3.0 to 5.11 without symptoms and those with symptoms of mood and disruptive disorders were recruited from primary care and daycare sites in the St. Louis area to participate in a psychiatric evaluation that included information about psychotropic prescriptions from community practitioners.

RESULTS

Seven percent of preschoolers (n = 19) out of a total sample of n = 267 were prescribed psychotropic medications. Fifty-two percent of preschoolers in the total sample met criteria for an Axis I psychiatric disorder. Presence of an Axis I disorder was significantly related to psychotropic prescription (p < 0.01). Among preschoolers who met criteria for an Axis I disorder 12% received psychotropics (Dx/Rx group). The Dx/Rx group was more impaired than those with a diagnosis who were not prescribed psychotropics (p < 0.001). Among preschoolers taking psychotropic medications, two failed to meet criteria for any Axis I disorder.

CONCLUSION

In this sample, most psychotropic medications were prescribed for impaired preschoolers with an Axis I diagnosis. These findings shed some light on the prescribing trends among mood and disruptive disordered preschoolers.

Defining and validating bipolar disorder in the preschool period

The clinical characteristics and adaptive functioning of preschoolers who met DSM-IV criteria for bipolar disorder versus psychiatric and healthy comparison groups were investigated. A community-based sample of 303 preschoolers (3-6 years of age) and their caregivers was ascertained. Diagnostic classification based on parent report of mania symptoms was made using an age-appropriate psychiatric interview. Results indicated that 26 preschoolers met DSM-IV criteria for bipolar disorder who could be identified based the presence of 13 core age-adjusted mania items. These children could be clearly differentiated from children in two psychiatric groups (DSM-IV disruptive disorders, and major depressive disorder) and a "healthy" comparison group based on a specific symptom constellation. Findings indicated that preschoolers in the bipolar group were significantly more (p < .05) impaired than the two psychiatric and healthy groups based on independent measures. Further, even after controlling for comorbid attention-deficit/hyperactivity disorder (81% comorbidity rate), the bipolar group remained significantly (p < .05) more impaired in multiple domains compared to preschoolers with DSM-IV disruptive disorders and healthy controls. Findings suggested that children as young as 3 years can manifest DSM-IV bipolar disorder when age adjusted symptom descriptions are employed, and that these children can be distinguished from healthy and disruptive disordered preschoolers. Recommendations for future research in this area that integrates developmental and mental health models are made.

Ten-year review of rating scales, VII: scales assessing functional impairment

OBJECTIVE

This is the seventh in a series of 10-year reviews of rating scales. Here the authors present scales measuring functional impairment, a sequela of mental illness. The measurement of functional impairment has assumed importance with the recognition that symptom resolution does not necessarily correlate with functional improvement.

METHOD

The authors reviewed functional impairment from multiple sources over the past 20 years. Thus, this article includes a variety of scales ranging from those that have been subject to critical review with strong psychometric support to those that have not been critically reviewed but are in widespread use to those that are still finding their niche.

RESULTS

These scales represent a continuum of constructs from symptoms to functional impairment to contextual factors that affect youths' functioning. Most older scales have focused on developmentally delayed youths. Newer scales strive to measure functional impairment separate from symptomatology. Some newer scales are also keyed to determination of level of service need.

CONCLUSIONS

Scales measuring functional impairment can elucidate the impact of illness on youths, identify targets for treatment, determine service needs, and monitor treatment effectiveness. These scales are widely used in community mental health and health service delivery. They can assist in providing evidence-based treatment.