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The Development and Well-BeingAssessment: Description and Initial

Validation of an Integrated Assessment of

Child and Adolescent Psychopathology

ARTICLE in JOURNAL OF CHILD PSYCHOLOGY AND PSYCHIATRY · AUGUST 2000

Impact Factor: 6.46 · DOI: 10.1111/j.1469-7610.2000.tb02345.x · Source: PubMed

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J. Child

Psycho/ . Psychinf . Vol.

41,

No.

5 ,

pp.

64. 55, 2000

Cambridge University Press

000 Association for Child Psychology and Psychiatry

Printed in G reat Britain. All rights reserved

0021-9630/00 I 15.00 0.00

The Development and Well-Being Assessment : Description and Initial

Validation of an Integrated Assessment of Child and Adolescent

Psychopathology

Robert Goodman, Tamsin Ford, and Hilary Richards

Institute of Psychiatry, London, U.K.

Rebecca Gatward and Howard Meltzer

Office for National Statistics, London, U.K.

The Development and Well-Being Assessment (DAWBA) is a novel package of question-

naires, interviews, and rating techniques designed to generate ICD-10 and DSM-IV

psychiatric diagnoses on 5-ldyear-olds. Nonclinical interviewers administer a structured

interview to parents about psychiatric symptoms and resultant impact. When definite

symptoms are identified by the structured questions, interviewers use open-ended questions

and supplementary prompts to get parents to describe the problems in their own words.

These descriptions are transcribed verbatim by the interviewers but are not rated by them.

A similar interview is administered to

1

l-16-year-olds. Teachers complete a brief

questionnaire covering the main conduct, emotional, and hyperactivity symptoms and any

resultant impairment. The different sorts of information are brought together by a computer

program that also predicts likely diagnoses. These computer-generated summary sheets and

diagnoses form a convenient starting point for experienced clinical raters, who decide

whether to accept or overturn the computer diagnosis (or lack of diagnosis) in the light of

their review of all the data, including transcripts. In the present study, the DAWBA was

administered to community

( N

= 491) and clinic ( N = 39) samples. There was excellent

discrimination between community and clinic samples in rates of diagnosed disorder. Within

the community sample, subjects with and without diagnosed disorders differed markedly in

external characteristics and prognosis. In the clinic sample, there was substantial agreement

between DAWBA and case note diagnoses, though the DAWBA diagnosed more comorbid

disorders. The use of screening questions and skip rules greatly reduced interview length by

allowing many sections to be omitted with very little loss of positive information. Overall, the

DAWBA successfully combined the cheapness and simplicity of respondent-based measures

with the clinical persuasiveness of investigator-based diagnoses. The DAWBA has

considerable potential as an epidemiological measure, and may prove to be of clinical value

too.

K eyw or h Diagnosis, epidemiology, interviewing, mental health, methodology.

Abbreviations: ADHD : attention deficit hyperactivity disorder; CAPA: Child and Ado-

lescent Psychiatric Assessment

;

DAWBA: Development and Well-Being Assessment ;

DISC: Diagnostic Interview Schedule for Children; NOS: not otherwise specified; SDQ:

Strengths and Difficulties Questionnaire.

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, De-

partment of Child and Adolescent Psychiatry, Institute of

Psychiatry, De Crespigny Park, London SE5

8AF,

U.K.

previous research findings, several related considerations

influenced the design

of

the DAWBA.

The Need

to

Measure

Impact

as Well as

Symptoms

Defining psychiatric disorder solely in terms of psy-

chiatric symptoms can result in implausibly high caseness

rates. For example, Bird et al. (1988) estimated from their

epidemiological study that 49.5 of Puerto Rican

children aged between 4 and 16 years met criteria for at

least one DSM-I11 diagnosis. As Bird et al. (1990) noted,

many of the children who were eligible for DSM-I11

diagnoses were not significantly socially impaired by their

symptoms, did not seem in need of treatment, and did not

correspond to what clinicians would normally recognise

645


3/12

646

R.GOODMAN et al.

as “cases”. This underlines the importance of defining

psychiatric disorders not only in terms of symptom

constellations, but also in terms of significant impact.

Including impact criteria can dramatically alter preva-

lence estimates. For example, in the Virginia Twin Study,

the population prevalence of DSM-111-R disorder was

41.8 ‘Yo as judged by symptoms alone, falling to

1

1.4 YO

when impairment criteria were included (Simonoff et al.,

1997). In DSM-IV (American Psychiatric Association,

1994), most of the common child psychiatric disorders

are now defined in terms of impact as well as symptoms;

operational criteria stipulate that symptoms must result

either in substantial distress for the child or in significant

impairment in the child’s ability to fulfil normal role

expectations in everyday life. This same requirement for

impact, in terms of significant distress or social inca-

pacity, characterises the diagnostic criteria employed in

the research version of ICD-10 (World Health Organ-

isation, 1994).

The Need fo r Multiple Informants

There are two main reasons why a comprehensive

assessment of child psychopathology depends on in-

formation about the child’s behaviour both at home and

at school. First, some diagnoses-most notably hyper-

kinesis (World Health Organisation, 1994) and attention

deficit hyperactivity disorder (ADHD ; American Psy-

chiatric Association, 1 9 9 4 h a n only be made when

there is evidence that the disorder is present in two or

more settings, usually home and school. Second, other

behavioural problems may be highly situational, e.g.

severe conduct problems may be present a t school but not

at home, or vice versa. The school perspective is also

important because troubled children and adolescents

commonly obtain help through the school system rather

than through mental health services (Burns et al., 1995).

Although it is possible to ask parents whether teachers

have complained of problems at school, it is clearly

preferable not to rely on such “hearsay’’ evidence but to

collect information directly from teachers as well as

parents. Young people’s self-reports can provide a

valuable third source of information. For example,

teenagers may describe worries or antisocial activities

that they have successfully hidden from the adults around

them.

Respondent-based Measu res Are E asier to

Administer

In a nationwide epidemiological study, it is much easier

and cheaper to use questionnaires and structured inter-

views (administered by lay interviewers) to obtain res-

pondent-based information on symptoms and impact

than to use semistructured interviews (administered by

clinical or highly trained interviewers) to obtain investi-

gator-based information. Questionnaires are particularly

suitable for teachers, who are often unable to spare the

time for interviews, especially for long investigator-based

ones.

Clinically Informed Ratings Enhance Validity and

Clinical Relevance

An exclusive reliance on respondent-based information

is liable to undermine validity and clinical relevance

;

clinically informed ratings are particularly useful at three

points in the diagnostic process :

(1) Clarifying symptoms and im pact.

Respondents do

not necessarily understand the wording of questions, and

even

if

they do, their answers may reflect unrealistically

high (or low) expectations of what can normally be

expected of children at any particular age. Giving

respondents the opportunity to describe any possible

problems in their own words will often enable a clinically

informed rater to recognise misunderstandings or un-

realistic standards.

2)

Combining information from different informants.

Having obtained information from multiple sources, how

can the diagnostic process integrate and reconcile con-

flicting information on symptoms and impact? There are

serious problems with many of the standard approaches.

One approach is to use a priori rules about whom to

believe, e.g. stipulating that teenagers are always better

than their parents at knowing if they are anxious or

depressed. Clinicians are likely to be suspicious of any

such rules, preferring to prioritise different informants

according to circumstances. For example, parents may

give a convincing account of their child being depressed,

whereas the child may insist that everything is fine,

whether out of bravado or a desire to be left alone.

Clinicians often choose to judge which informant to

believe from the quality of the narrative and other subtle

clues. A previous study has shown that clinically informed

raters can synthesise multi-source information in a way

that is both reliable and valid (Goodman, Yude,

Richards, 8z Taylor, 1996).

A second approach to combining multi-source in-

formation is to believe anyone who reports a positive

symptom or impairment. This is sometimes known as the

“O R” rule, since symptom

X

is deemed to be present if a

parent

or

a teacher

or

the young person reports it.

Unfortunately, this approach is bound to push up

apparent rates of disorder since false positive answers

always take priority over true negative ones. If you asked

enough informants-parents, grandparents, neighbours,

friends, teachers, and

so

on-then many symptoms would

be present according to someone.

A third approach is to abandon any attempt at

integration and simply report rates of disorders separately

according to the type of informant, e.g. reporting that the

rate of depressive disorders in teenagers is, say,

20

by

their own account, 5 by their parents’ account, and 1

by their teachers’ account. This approach fails to address

some of the key concerns of clinicians and service

planners. Clinicians often need to make binary de-

cisions-such as whether to treat or not to treat-in the

face of conflicting accounts. Service planners need to

know whether to provide depression clinics for

1

or

20

of the teenage population.

( 3 ) Assigning “not otherwise specified”

( N O S )

diag-

noses.

Despite having psychiatric symptoms that result

in distress and social impairment, some children do not

meet the full criteria for an operationalised diagnosis

such as ADHD, separation anxiety disorder, or oppo-

sitional defiant disorder. With clinical judgement, these

children can be assigned nonoperationalised diagnoses,

e.g. ADHD,

NOS;

anxiety disorder,

NOS;

disruptive

behavior disorder, NOS. A substantial minority of

children with psychiatric disorders may “fall between the

cracks”’ of the operationalised diagnostic categories

(Angold, Costello, Farmer, Burns, & Erkanli, 1999;


4/12

DEVELOPMENT AND WELL-BEING ASSESSMENT 647

Goodman et al.,

1996). Using clinical judgement to

recognise nonoperationalised disorders need not under-

mine reliability and validity (Goodman et al., 1996).

A Focus

on

the Present State

There are two main reasons why it is preferable to ask

abou t the present and the recent past rather than abou t

the child’s lifetime history of emotional and behavioural

problems. First, enquiries about long time frames are

generally of unsatisfactory validity (Tanur, 1992), and

one recent investigation into methods for assessing the

prevalence

of

child and adolescent mental disorders

recommended focusing enquiries

on

the last month if

possible (Shaffer

et

al., 1996). Second, for

a

study focusing

on service planning, the need for services is clearly related

to ongoing problems rather than to problems that have

long since resolved.

The Prevalence of Uncommon Disorders Requires a

Diflerent Approach

Even with

a

sample size of

over

10,000children from

the general community, it is not possible to generate

precise estimates of less common disorders such as

psychosis or selective mutism because these are only

likely to affect

a

handful of children in the sample.

Consequently, it

is

not appropriate to devote

a

lot of

interview time asking about

these

less

common

disorders.

Predicting the service need for

rare

but severe disorders

is

likely

to require

a

very different strategy, such as

surveying all the clinics and clinicians in

a

region.

Method

ver view

The DAWBA measures were administered along with in-

dependent 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 examin-

ations. The diagnosis of clinic cases was independently es-

tablished 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 and 15, the Office for National Statistics used

experienced nonclinical interviewers to carry out a survey of

children drawn from 12 different 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 (1

5

YO efusal,

3YO

oncontacts). 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 interview was available for all but 1 of the 491 community

subjects. There were 207 subjects aged between 11 and 15, of

whom 201 (97 ) were interviewed. Nearly all 491 families gave

their permission for a teacher to be contacted by postal

questionnaire completed teacher questionnaires were returned

on 353 children (72 ). For the community sample as a whole,

the mean age SD) as

9.9

years (3.2), and 51 were male.

Although the pilot sample was drawn from 12 areas chosen to

provide a good geographical spread while being fairly rep-

resentative, he sample was not selected and weighted to provide

an unbiased estimate of the true prevalence of psychiatric

disorder in British 5-1 5-year-olds-better estimates are avail-

able from the subsequent survey of over 10,000 children

(Meltzer et al., 2000).

Psychiatric Clinic Sample

In

parallel with the pilot study of community subjects, non-

clinical interviewers from the Office for National Statistics

assessed 39 subjects recruited from 3 child and adolescent

mental health clinics in Manchester and London. These clinic

subjects had all had a clinical assessment and nearly all were still

receiving treatment from the clinic when reassessed as part of

the current study. A parent interview was available for all clinic

subjects. There were 20 subjects aged between 11 and 15, of

whom 16 (80 )were interviewed. Completed teacher question-

naires were obtained on 17 children

(44 ).

For the clinic

sample as a whole, the mean age

SD)

as 11.0 years (2.6), and

79 were male. The community and clinic samples differed

significantly in age [t(527) = 2.1, p < .05] and gender [con-

tinuity-adjusted ~ ~ ( 1 )10.5,p < .001]. Although these gender

and age differences were not taken into account in the analyses

reported here, the pattern of findings was not altered when

analyses were repeated after stratifying the sample by age or

gender.

The Development and Well-Being Assessment

( D AWB A )

The DAWBA involves four components: a parent interview,

an interview for young people aged 11 or more, a teacher

qqestionnaire, and a computer-assisted clinical diagnostic

rating based on the interviews and questionnaires. The measures

were designed with 5-1 6-year-olds n mind, though the measures

were not applied to 16-year-olds in the present study since

a previous nationwide survey of adult mental health had al-

ready included 16-year-olds (Meltzer, Gill, Petticrew,& Hinds,

1995). The DAWBA interviews and questionnaires are available

from http://www.iop.kcl.ac.uk/IoP/Departments/ChildPsy/

dawba/intro.stm along with a more detailed account of the

measures. As an indication of the length of the measures, the

paper version of the parent interview is 36 sides long and takes

around 50 minutes to administer to a community sample

(provided the skip rules described below are in use). The

corresponding youth interview is 33 sides long and takes around

30 minutes to administer to a community sample. The teacher

questionnaire is four sides long. In the present study, th

interviews were computer assisted, with the interview being

programmed in Blaise (Statistics Netherlands). The survey

interviewers had no experience of child psychiatric surveys

beyond a 1-day introduction to the field; all the interviewers

found the interviews challenging but feasible and interesting,

and all were keen to participate in the subsequent main stage

study. The parents and young people who were interviewed

were also generally very positive about the study.

The D A WBAparent interview. The interview covers several

disorders in detail : separation anxiety, specific and social

phobias, post-traumatic stress disorder, obsessive compulsive

disorder, generalised anxiety, rnaj6r depression, hyperkinesis/

ADHD, and conduct-oppositional disorders. For each of these

disorders, the interview asks about all the symptoms and other

criteria needed for an operationalised diagnosis according to

both DSM-IV (American Psychiatric Association, 1994) and

the research diagnostic version of ICD-10 (World Health

Organisation, 1994). Panic disorder, agoraphobia, autistic

disorders, eating disorders, tic disorders, and any other concerns

https://www.researchgate.net/publication/270108290_Questions_About_Questions_Inquiries_into_the_Cognitive_Bases_of_Surveys?el=1_x_8&enrichId=rgreq-cee00174-3000-4b57-93b9-88245b22165c&enrichSource=Y292ZXJQYWdlOzEyMzczNTQ5O0FTOjk3MDE2OTY5NDMzMDk1QDE0MDAxNDIwNTY4MjA=https://www.researchgate.net/publication/270108290_Questions_About_Questions_Inquiries_into_the_Cognitive_Bases_of_Surveys?el=1_x_8&enrichId=rgreq-cee00174-3000-4b57-93b9-88245b22165c&enrichSource=Y292ZXJQYWdlOzEyMzczNTQ5O0FTOjk3MDE2OTY5NDMzMDk1QDE0MDAxNDIwNTY4MjA=


5/12

648

R.

GOODMAN et al.

are covered more briefly, with clinical diagnoses of these

disorders being correspondingly more dependent on rating the

open-ended transcript.

The time frame of the interview is the present and the recent

past. For many disorders, the ICD-10 and DSM-IV diagnostic

criteria stipulate that the symptoms need to have persisted for a

specified number of months, e.g. a minimum of 6 months for

hyperactivity, oppositional-defiant disorder, and generalised

anxiety disorders. In these instances, the relevant section of the

DAWBA interview focuses on the child’s symptoms over this

stipulated period. The time frame is longest for conduct disorder

(since DSM-IV criteria include the number of relevant be-

haviours displayed over the previous 12 months), and shortest

for most of the emotional disorders, where the focus is on the

last month, in line with previous recommendations (Shaffer et

al., 1996).

The interview incorporates skip rules” that allow the

interviewer to omit many of the questions in a section unless

enough screening questions are positive. When the skip rules do

not operate, respondents are asked about all relevant ICD-10

and DSM-IV symptoms. Unless at least one of these symptoms

is definitely present (or two symptoms in the case of the

hyperactivity section), the final interview questions about

duration, onset, and impact are omitted. The skip rules were

formulated and refined during the pre-pilot study. To determine

if these skip rules worked satisfactorily in an independent

sample, the interviews in the current study were administered

without skip rules on around half of the community subjects

and on all the clinic subjects( N = 262). This made it possible to

examine the number of instances in which a “positive” section

would have been inappropriately omitted had the skip rules

been operational. An interview section was counted as positive

if the responses to that section met the ICD-10 or DSM-IV

criteria for a disorder. The section was also counted as positive

if the respondent reported subthreshold symptoms and impact

but the clinical reviewer subsequently assigned the relevant

diagnosis.

In the presence of positive symptoms in any domain, parents

are asked supplementary questions about the

impact

of these

problems on the child’s life. These domain-specific impact

questions cover resultant distress and interference with family

life, learning, friendships, and leisure activities.

The information elicited by the structured questions about

symptoms and impact is supplemented by semistructured

information.If definite symptoms are identified by the structured

questions, interviewers are instructed to use open-ended ques-

tions and supplementary prompts to get the respondent to

describe the problems in their

own

words. These descriptions

are transcribed verbatim by the interviewers but are not rated

by them. Interviewers are also encouraged to provide additional

comments, where appropriate, on the respondents’ under-

standing and motivation.

The DAW BA interview fo r 11-16-year-olh.

In most re-

spects, the interview for 11-16-year-olds is exactly the same as

the interview for parents, except that it is in the first rather than

the third person. The sections on hyperactivity and opposition-

ality are much abbreviated, since previous work suggests that

youth self-report in these domains is of very limited validity

(Schwab-Stone et al., 1996). Conversely, more questions about

panic attacks were asked of young people than of parents since

the fleeting and largely subjective nature of these symptoms

makes self-report far more relevant than informant accounts.

A

lower limit of 11 years stemmed from previous studies showing

that symptoms are not reliably reported by younger children

(Fallon

&

Schwab-Stone, 1994; Schwab-Stone, Fallon, Briggs,

& Crowther, 1994) and from similar experience during pre-

piloting of the DAWBA with 8-10-year-olds.

The

D A

WBA questionnaire fo r teachers. The teacher ques-

tionnaire covers the inattentive, impulsive, hyperactive, and

oppositional-conduct behaviours relevant to ICD- 10 and DSM-

IV diagnostic criteria, and also asks about common emotional

symptoms and any other concerns. Reports of definite problems

in the hyperactivity, conduct, or emotional domains are

followed by supplementary questions on the impact of these

problems on the child’s life. These domain-specific impact

questions cover resultant distress and interference with learning

and peer relationships. There are free text sections throughout

the questionnaire for descriptions of problems or additional

concerns.

Computer-assisted clinical diagnosis. Experienced clinicians

review the data from all sources-structured interviews, ques-

tionnaires, and transcripts from parents, young people, and

teachers-before assigning each child ICD-

10

and DSM-IV

diagnoses (or no diagnosis). For ease and speed of rating, the

different sorts of information are brought together by computer.

The raters are also assisted by computerised diagnostic algo-

rithms that determine whether the child meets the opera-

tionalised criteria for the commoner ICD-10 and DSM-IV

diagnoses, as judged from the respondents’ answers to struc-

tured questions. The computer diagnoses are not definitive, but

simply form a convenient starting point for the clinical raters

who decide whether to accept or overturn the computer

diagnosis (or lack of diagnosis) in the light of their review of all

the data, including transcripts.

The clinical raters perform four major tasks. First, they use

the transcripts to check whether respondents appear to have

understood the fully structured questions. Second, they decide

which informant to believe when presented with conflicting

information. Third, they assign a “not otherwise specified

”

diagnosis when the child has clinically significant problems that

do not meet operationalised diagnostic criteria. Fourth, they

use information from the transcripts to diagnose less common

disorders such as anorexia nervosa or Tourette syndrome. In

the current study, the clinical ratings were done by two

experienced child psychiatrists (HR,

RG),

who discussed all

children with complex or borderline diagnoses before reaching

a consensus diagnosis.

External Validating Characteristics

Various measures of the community sample were obtained

independently of the DAWBA measures. Several of these

measures served as external validators of the DAWBA di-

agnosis. Parents, teachers, and young people over the age of l l

all completed the extended version of the Strengths and

DifEiculties Questionnaire (SDQ; Goodman, 1999).Thisversion

of the SDQ includes a question that asks respondents if they

think that the child “has difEiculties in one or more of the

following areas: emotions, concentration, behaviour, or being

able to get on with other people”. Possible response categories

are “No”, “Yes-minor difficulties”, “Yes-definite diffi-

culties” and ‘‘Yes-severe difficulties

”.

The definite and severe

difficulties categories were combined to form the basis for three

variables: “Parents say there is a problem”, “Teacher says

there is a problem”, and “Young person says there is a

problem”. Parent, teacher, and self-completed

SDQs

were also

used to generate emotional, conduct, and hyperactivity scores

in the standard manner (Goodman, 1997; Goodman et al.,

1998). The parent interview included questions on recent

consultations with child and adolescent psychiatrists, psycholo-

gists, psychotherapists, or psychiatric nurses. Consultations

with one or more of these professionals formed the basis for the

variable “Mental health care provided

”.

The teacher ques-

tionnaire asked whether the child had received “any specific

help for emotional or behavioural problems from teachers,

educational psychologists, or other professionals working

within the school setting” during that school year. This question

formed the basis for the variable “School help provided”.

Clinical Case Note Diagnosis

An experienced child psychiatrist TF) who was blind to the

DAWBA findings reviewed the case notes of all 39 children

from the psychiatricclinic sample to determine which diagnoses,

if any, the child would have met a t the time when the DAWBA

https://www.researchgate.net/publication/12867176_The_Extended_Version_of_the_Strengths_and_Difficulties_Questionnaire_as_a_Guide_to_Child_Psychiatric_Caseness_and_Consequent_Burden?el=1_x_8&enrichId=rgreq-cee00174-3000-4b57-93b9-88245b22165c&enrichSource=Y292ZXJQYWdlOzEyMzczNTQ5O0FTOjk3MDE2OTY5NDMzMDk1QDE0MDAxNDIwNTY4MjA=https://www.researchgate.net/publication/12867176_The_Extended_Version_of_the_Strengths_and_Difficulties_Questionnaire_as_a_Guide_to_Child_Psychiatric_Caseness_and_Consequent_Burden?el=1_x_8&enrichId=rgreq-cee00174-3000-4b57-93b9-88245b22165c&enrichSource=Y292ZXJQYWdlOzEyMzczNTQ5O0FTOjk3MDE2OTY5NDMzMDk1QDE0MDAxNDIwNTY4MjA=https://www.researchgate.net/publication/12867176_The_Extended_Version_of_the_Strengths_and_Difficulties_Questionnaire_as_a_Guide_to_Child_Psychiatric_Caseness_and_Consequent_Burden?el=1_x_8&enrichId=rgreq-cee00174-3000-4b57-93b9-88245b22165c&enrichSource=Y292ZXJQYWdlOzEyMzczNTQ5O0FTOjk3MDE2OTY5NDMzMDk1QDE0MDAxNDIwNTY4MjA=


6/12

DEVELOPMENT AND WELL-BEING ASSESSMENT 649

measures were administered. Because of small cell sizes, case

note diagnoses were merged into three categories for most

analyses : hyperkinesis or ADHD; oppositional or conduct

disorders; and emotional disorders (anxiety and depressive

disorders). For each category, disorders were rated as absent,

possible, or definite. Using this system, 2 researchers inde-

pendently rated 20 case notes from

1

of the clinics used in the

present study; the kappa coefficients were

.93

for hyperkinesisl

ADHD, 1

O

for oppositional-conduct disorders, and

.67

for

emotional disorders (Goodman, Renfrew,

&

Mullick, unpub-

lished data). In the present study, DAWBA and case note

diagnoses were not compared until each had been finalised

independently of the other. At this stage, agreement was

examined for each broad-band diagnosis. Overall agreement

between the detailed DAWBA and case note formulations was

also examined, being rated on a 3-point scale: 0 = poor

agreement,

1

= partial agreement, and

2

= substantial or total

agreement. When 2 psychiatrists independently made this rating

on all 39 clinic cases, the kappa was .64.

Questionnaire Follow-up

Between 4 and 6months after the original assessment, a

postal copy of the SDQ was sent to the 471 parents who had

originally been recruited into the community sample via child

benefit records. Complete SDQ data was available both initially

and at follow-up on 350 individuals

(74

). The total difficulties

score was calculated in the standard manner (Goodman, 1997).

Results

Comparing C omm unity 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 com-

parison 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

DAWBA measures would support their validity. It was

not necessary to assume that all clinic cases still had a

psychiatric disorder at the time of the DAWBA as-

sessment, nor was it necessary to assume that community

cases

were

free from all psychiatric disorder. As shown in

Table

1,

there were marked differences between the rates

of DAWBA-diagnosed disorders in the community and

clinic samples, with odds ratios between

13

and 102. At

least one ICD-10 or DSM-IV disorder was diagnosed in

1

1

YO

f the community sample as compared with 92 of

the clinic sample. This corresponds to a minimum

estimate of 89 specificity in the community sample and

92 sensitivity in the clinic sample (based on the extreme

and implausible assumption that all of the community

sample with DAWBA diagnoses were false positives and

all of the clinic sample without psychiatric diagnoses were

false negatives).

The C ommunity Sample

The second approach to validation considered only the

community sample. If the DAWBA measures were valid,

then individuals with and without DAWBA diagnoses

should differ in predictable ways on independent

measures. Children with a DAWBA diagnosis were

predicted to be substantially more likely to be known to

child mental health professionals, to be receiving help for

emotional or behavioural problems at school, and to be

judged to have a psychiatric problem by parents, teachers,

or the young people themselves. All these predictions

were confirmed with odds ratios of between 8 and 27

(Table 2). Children with different categories of DAWBA

diagnoses-motional, conduct, or hyperactivity dis-

orders-were predicted to have contrasting profiles

of

SDQ scores in these domains. This was indeed the case:

for each disorder and each class of rater (parent, teacher,

self), the highest SDQ scores were in the predicted domain

Table 1

Rates of D A W B A Diagnoses in Community and Clinic Children

Psychiatric clinic Community Odds

sample

( N

= 39) sample ( N = 491) ratio

Any disorder

92.3 o (36) 10.6 (52) 101.3

Anxiety disorder

43.6 (17)

5.5

(27)

13.3

Major depressive disorder 20.5

(8) 0.8 (4) 31.4

Conduct-oppositional disorders

46.2 Yo (18) 3.5 (17) 23.9

Hyperkinesisb 41.0 (16) 1.4 (7) 48.1

ADHD'

48.7 (19) 2.4 (12) 37.9

ICD-10 or DSM-IV.

ICD- 10.

SM-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 Comm unity Sample

DAWBA No DAWBA Odds

diagnosis ( N = 52)

diagnosis

( N = 439)

ratio

Teachers say there is a problem

50.0

(18/36) 7.3 (23/317) 12.8

Young person says there is a problem

25.0 (6/24) 4.1 (7/177)

8.1

Mental health care provided

26.9 (14/52) 1.4 (6/438) 26.5

Parents say there is a problem 38.5 (20/52) 2.7 (12/438) 22.2

School help provided

41.6 (15/36) 5.7 (18/317) 11.9

p

< .001 for all comparisons of children with and without DAWBA diagnoses (continuity

adjusted x ).

https://www.researchgate.net/publication/13963887_Strengths_and_Difficulties_Questionnaire_(SDQ_T418)?el=1_x_8&enrichId=rgreq-cee00174-3000-4b57-93b9-88245b22165c&enrichSource=Y292ZXJQYWdlOzEyMzczNTQ5O0FTOjk3MDE2OTY5NDMzMDk1QDE0MDAxNDIwNTY4MjA=https://www.researchgate.net/publication/13963887_Strengths_and_Difficulties_Questionnaire_(SDQ_T418)?el=1_x_8&enrichId=rgreq-cee00174-3000-4b57-93b9-88245b22165c&enrichSource=Y292ZXJQYWdlOzEyMzczNTQ5O0FTOjk3MDE2OTY5NDMzMDk1QDE0MDAxNDIwNTY4MjA=https://www.researchgate.net/publication/13963887_Strengths_and_Difficulties_Questionnaire_(SDQ_T418)?el=1_x_8&enrichId=rgreq-cee00174-3000-4b57-93b9-88245b22165c&enrichSource=Y292ZXJQYWdlOzEyMzczNTQ5O0FTOjk3MDE2OTY5NDMzMDk1QDE0MDAxNDIwNTY4MjA=


7/12

650

R.

GOODMAN

et al.

Emotional

disorders

Figure I SDQ profiles of community children with different DAWBA diagnosis.

(Fig. 1). Children with DAWBA diagnoses were predicted

to have more persistent problems than comparably

symptomatic children without diagnoses, as confirmed by

the results shown in Fig. 2. Of the 350 children who were

assessed using parent SDQs both initially and at follow-

up 4-6 months later, 35 had a DAWBA diagnosis; as a

group, their SDQ total difficulties score did not fall with

time. Of the remaining children without DAWBA diag-

noses, there were 63 children who scored in the top 20

on

total difficulties score; as a group, they regressed

substantially towards the mean. The lack of regression

towards the mean in the DAWBA-diagnosed group was

significant, with the presence or absence of

a

DAWBA

diagnosis predicting Time 2 score after covarying for

Time 1 score

( p

<

.002 .

The Clinic

Sample

The th’ird approach to validation considered only the

clinic sample. How far did the DAWBA and case note


8/12

DEVELOPMENT AND WELL-BEING

ASSESSMENT

65

Diagnosed disorder

N=35)

.............

........................

.................

12 NOdisorder

ean

o

Q

Score

high scorers

N=63)

No disorder low scorers

(N=252)

*------------

.

(Parent-rated)

0 ‘

Initial survey 4-6 month

fol low-up

Figure

2. DAWBA-identified caseness predicts persistence of problems.

Table 3

D A WBA and C ase Note D iagnoses on the C linic Sample

DAWBA diagnosis

Case

note

diagnosis

Absent Possible Definite

Emotional disorders (ICD-10 or DSM-IV)

Absent

16

4

0

Present

6

6

7

~ ~ ( 1 )

rend = 11.6,p = .001; Kendall’s

tau

b

= 0.52

Conduct-oppositional disorders (ICD-10or DSM-IV)

Absent 11

9

1

Present 2 10 6

~ ~ ( 1 )

or

trend = 9.4,

p

=

.002;

Kendall’s tau

b

= 0.47

ADHD-hyperkineticdisorders (ICD-10or DSM-IV)

Absent

16

3 1

Present 3 1 15

~ ~ 1 )

or trend = 2 0 . 3 , ~ .001; Kendall’s tau b = 0.70

diagnoses coincide? The underlying assumption was that

if the DAWBA were a valid measure, there should be

substantial overlap between the DAWBA formulation

and the independent formulation of a good psychiatric

clinic. The diagnosis based on case note review was not

considered the “gold standard” that could form the basis

for calculating sensitivity and specificity. This was partly

because the clinical assessments were not standardised

and were carried out by a variety of professionals of

different levels of seniority. In addition, case notes were

often insufficiently detailed for a “definite” rating of

disorder, leading the researcher to opt in many cases for

a “possible” rating instead; this was particularly a

problem for comorbid diagnoses since case notes often

focused on what the clinician regarded as the primary

diagnosis.

Table

3

shows the cross-tabulation of DAWBA and

case note diagnoses for each of the three main diagnostic

groupings : emotional disorders, conduct disorders, and

hyperkinesis/ADHD. Review of the psychiatric clinic

notes suggested a definite diagnosis in 1 of these areas in

30 instances; the DAWBA diagnosed the same disorder

in 28 instances (93 ). However, the DAWBA also

diagnosed disorders that were not rated as “definitely

present” on the basis of a case note review-1

7

of these

28 “false positives” had been rated from the case notes as

having “possible” rather than “absent” disorders. Fur-

thermore, 19 of the DAWBA’s 28 false positives were of

comorbid diagnoses, i.e. the DAWBA agreed with the

principal diagnosis reported in the case notes but also

diagnosed

1

or more additional disorders. Overall agree-

ment between the DAWBA and case note formulations

on the 39 clinic cases was classified as substantial or total

in 49 (19/39), partial in

46

(18/39), and poor in 5

(2/39). The DAWBA correctly identified all six children

with case note diagnoses of “less common” disorders:


9/12

652

R .

GOODMAN et al.

Table 4

EfJicacy of Skip Rules

Proportion who

Positive cases skip section

misseda with

Disorder Informant skip rules Communityb Clinicc

78 31

77 56

77 33

72 37

79 31

79 56

93

y

77

91 62

83

Yo

33

79 Yo

50

77 y 36

74 Yo 37 y

61 26

45

y

31 y

73 10

DHD/Hyperkinesis Parent

1/23

Oppositional-defiant disorder Parent

1/16 76 Yo 23

y

91 28

71 Yo 62 o

Average 4

(61142) 76

40

been applied.

people were interviewed without skip rules.

people were interviewed without skip rules.

Separation anxiety Parent 18

Child

012

Child

012

Child

0/4

Specific phobia Parent

2/14

Social phobia Parent

019

Post-traumatic stress disorder Parent

015

Child

014

Obsessive-compulsive disorder Parent

113

Child

013

Child

017

Child 15

Conduct disorder Parent

019

Child

117

Generalised anxiety Parent

0114

Depression Parent

017

a “Missed cases” are those where a positive section would have been skipped had the skip rules

bCommunity sample=

223

subjects: all parents interviewed without skip rules;

91

young

Psychiatric clinic sample

= 39

subjects all parents interviewed without skip rules; 16young

three with pervasive developmental disorders, one with

schizophrenia, one with anorexia nervosa, and one with

Tourette syndrome.

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 screen-

ing 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 inappropri-

ately had the skip rules been operating. Table 4 shows

that 4.2 (95 confidence interval 0.9-7.5

)

of posi-

tive 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; he corresponding proportion for

clinic cases was 40

.

er urning Computer

Diagnoses

The clinical raters found the computer-assigned diag-

noses helpful as a starting point for their clinical review

and formulation. Nevertheless, the clinician-assigned

diagnoses commonly differed from the computer-as-

signed diagnoses. Thus 43 (8.8

)

of the 491 community

subjects had an ICD- 10 or DSM-IV diagnosis according

to the computerised algorithms; he clinical raters judged

11 (2.2%) of these subjects not to have a psychiatric

disorder (false positives) while giving diagnoses to an

additional 20 subjects (4.1

)

who had not been diag-

nosed 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 ex-

amples of subjects whose computer-assigned diagnoses

were changed by the clinical raters.

Subject I Excluding

a

computer-assigned diagnosis.

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 com-

puter algorithm’s 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 more‘than 2 minutes at a time even on activities she

enjoyed, and had been offered a trial of medication. The


10/12

DEVELOPMENT AN D WELL-BEING ASSESSMENT

653

clinician concluded that the teacher’s report of minimal

impairment was an understatement, allowing a clinical

diagnosis of ADHD to be made.

Subject 3:

Both

adding to and subtracting

rom

com-

puter-assigned diagnoses. A 14-year-old girl received

computer-assigned diagnoses of simple phobia, major

depression, and oppositional-defiant disorder. Both the

girl and her mother had also answered “yes” to the

interview question about concern about dieting or thin-

ness. The transcripts of the open-ended comments pro-

vided by the girl and her mother included convincing

descriptions not only of a depressive disorder but also of

anorexia nervosa of 1 year’s duration. The supposed

phobia was an anorexic fear of food, and the opposition-

ality had only been present for a year and was primarily

related to battles over food intake. Consequently, the

clinical rater made the additional diagnosis of anorexia

nervosa and overturned the diagnoses of simple phobia

and oppositional-defiant disorder.

,

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 Diag-

nostic 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 clinician-

generated 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 pres-

ence and severity of symptoms and resultant impair-

ments. These interviewer-based ratings can form the basis

for computerised diagnostic algorithms. The clinical

rating involved in the DAWBA fulfils a similar role but

has some distinctive disadvantages and advantages. With

a traditional semistructured interview, the person who

rates the symptoms is the same person who carries out the

interview, so interviewers can go on asking questions and

clarifying details until they are confident that they can

make their ratings. By contrast, the DAWBA clinical

raters have to judge whether symptoms were present or

not on the basis of the answers obtained by lay inter-

viewers at some earlier time. Detailed transcripts of

answers to open-ended questions generally provide

enough information

to

do this, but when they do not, the

clinical raters cannot themselves ask supplementary ques-

tions. This undoubted disadvantage is offset by a major

economy-expensive and scarce clinical time is not

wasted either on routine interviewing or on travelling to

and from households scattered over a large geographical

area. The main stage survey that followed this study used

over

200

lay interviewers “in the field” but only required

three clinical raters “back at base”. In addition, the

DAWBA clinical raters combine information from all

sources to make two important judgements

:

which

informants to prioritise when there is a clash of in-

formation, and whether to assign “not otherwise speci-

fied

”

diagnoses when children have substantial problems

that do not meet operationalised diagnostic criteria.

These two key judgements cannot generally be made a t

the time of the initial interviews, whether semistructured

or not, which is part of the rationale for the DAWBA

method of using clinical input at the “overview” rather

than the “interview

”

stage.

The DAWBA’s manner of combining the cheapness

and simplicity of respondent-based measures with the

clinical persuasiveness of investigator-based measures is

novel. Previously, researchers wanting to combine the

advantages of respondent- and investigator-based meas-

ures have used multi-phase designs. For example, many

studies have used screening questionnaires or structured

interviews in a first phase and have then selected screen-

positive and some screen-negative subjects for a second

phase involving semistructured interviews administered

by clinically trained interviewers (e.g. Costello et al., 1996;

Rutter, Cox, Tupling, Berger, & Yule, 1975; Taylor,

Sandberg, Thorley,

&

Giles, 1991). By contrast, the

DAWBA approach combines respondent- and investi-

gator-based measures in a single phase, which has several

practical advantages including ease of analysis and

avoidance of the risk of families dropping out between

phases (Deming, 1977). Although common sense suggests

that interviewing all families is bound to be considerably

more expensive than a multi-stage design that only

involves interviewing a proportion of families, this is not

necessarily true (Newman, Shrout,

&

Bland, 1990). To

estimate prevalence with adequate precision in a multi-

phase study, it is often necessary to interview a sur-

prisingly high proportion of screen-negative subjects.

When this requirement is combined with the need for

repeated visits to families who are participating in more

than one phase, then the economies of the multi-phase

design are generally modest unless the disorder is rare and

the screening test has excellent sensitivity and specificity.

When the benefits of a multi-phase design are modest, the

other advantages of a one-phase design may commend it

to researqhers. The DAWBA seems to be a suitable

assessment battery for a one-phase study that aims to

combine respondent- and investigator-based measures.

,


11/12

654 R. GOOD MA N et al.

Alternatively, the DA W BA can be used as a second phase

in a two-phase study.

The current study examined validity rather than

reliability. Of course, the evidence for validity provides

indirect evidence for reliability too ; a n unreliable set of

me asures would also have do ne poo rly o n tests of validity.

A previous study of the clinical rating system incor-

porated in to the DAW BA showed that the method was of

satisfactory inter-rater reliability with kap pas of aro und

.7 (G oo dm an et al., 1996). Fu rth er tests of the inter-rater

reliability of the clinical rating component of the

DA W BA are currently under way.

Ideally, we would have wanted to measure the test-

retest reliability of t h e DAWBA o n a large sample of

children from psychiatric clinics and the comm unity. W e

would a lso have l iked to compare the DAWBA with

oth er well-established assessments, including respondent-

based measures such as the DISC (Shaffer et al., 1996)

and investigator-based measures such as the CAPA

(Ang old e t al., 1995).

It

was no t possible to do

this,

partly

because we did not wish to over-burden families whom

we wanted to engage in a longitudinal study.

In

addition,

however, designs that involve administering two lengthy

interviews in fairly rapid succession ar e problematic. T he

main problem is that participating in the first interview

markedly alters the way respon dents behave in th e second

interview (e.g. Jensen et al., 1995). Particularly in com-

munity samples, respondents admit to fewer problems o n

the second interview, perhaps in

part

because they are

bored w ith the process and w ant

to

get it over with faster.

This attenuation of “yes” responses is more marked if

the interv al betw een interviews is brief, but increasing the

interval to avoid this leads instead to

a

different problem ,

namely that the child’s me ntal s tate is m ore likely to ha ve

changed in the interim. In effect, the re is

a

“psychiatric

unce rtainty principle”: it is not possible to assess psy-

chopathology b oth accurately an d frequently because the

most accurate measures are too long to be repeated

without inducing respondent fatigue, while the most

repeatable measures a re less accurate a s a consequence of

their brevity. This poses serious problems for the in-

vestigator wh o wan ts to establish the test-retest reliability

of a lengthy assessment-measured reliability is likely t o

be artefactually low. Comparing the validity of two

lengthy assessments is potentially less problematic since

subjects

can

potentially be randomised to receive one

measure or the other, subsequently comparing the two

measures in terms

of

conc urren t an d predictive validity,

and also mo netary cost.

It

will be impo rtant

in

the future

to compare the DAWBA with o ther respondent- or

investigator-based assessment tools, both in epidemio-

logical a nd clinical settings.

Acknowledgements-We are very grateful to all the parents,

teachers, children, and interviewers who took part in the

study, to the staff of the three pa rticipating psychiatric clinics

(Royal Manchester Children’s Hospital;Withington Hospital,

Manchester; Department of Child and Adolescent Psy-

chiatry, Hounslow), to Pippa Hoad, Helen Simmons, and other

colleagues. The study was funded by the Departm ent of

Health.

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Manuscript accepted 17 January 2000

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