Psych Profiler Manual

Phone: (08) 9388 8044
PO Box 502 SUBIACO

WESTERN AUSTRALIA 6904
www.pecs.net.au
psychprofiler manual
© Langsford1, Houghton2, & Douglas3 (2005)

1
Dr Shane Langsford, Psychological & Educational Consultancy Services
2
Professor Stephen Houghton, University of Western Australia
3
Dr Graham Douglas, University of Western Australia
psychprofiler software developed by Strategy West Consulting

CONTENTS
Page
List of Tables v
List of Figures v
List of Abbreviations vi
Author Information viii

psychprofiler instrument viii
Dr Shane Langsford viii
Professor Stephen Houghton viii
Dr Graham Douglas viii
Software development viii

Mr Lindsay Jamieson viii
the psychprofiler
Instrument Description 1
Instrument title 1
Instrument components 1
Disorders included in the psychprofiler 2
Completion and Scoring Procedures 2
Validity and Reliability 3
Reporting 3
Example APP report 4
Appendix A: Report interpretation guidelines 7
Appendix B: Brief definitions for each disorder 8
Utilisation Options 10
Pencil-and-paper checklist 10
psychprofiler software program 10
Online versions of the psychprofiler 10
Ways in Which the psychprofiler Can Improve Assessment and Treatment 11
Competing Instruments 13
Theoretical Basis of the Instrument 14

Introduction 14
Definition of disorder 14
Methodological inconsistencies 14
Prevalence of child and adolescent disorder 16
Comorbidity among disorders 16
Chapter summary 17
Literature review 18
Prevalence of child and adolescent disorder 18
Prevalence of individual disorders 20
Influence of Gender on disorder 24
Influence of Age on disorder 25
Influence of Socioeconomic Status on disorder 25
ii
Page
Factors contributing to the nonidentification of disorder 26
Contribution of Gender to the nonidentification of disorder 27
Contribution of Age to the nonidentification of disorder 27
Contribution of Informant to the nonidentification of disorder 28
Contribution of comorbidity to the nonidentification of disorder 30
Contribution of instrumentation to the nonidentification 31
Structured interviews 31
Diagnostic Interview Schedule for Children 31
Checklists 31
International Statistical Classification of Diseases and Related Health Problems 32
Diagnostic and Statistical Manual of Mental Disorders 32
Adolescent Symptom Inventory-4 32
Child Behaviour Checklist 32
Strengths and limitations of interviews and checklists 33

Interviews 33
Checklists 33
Interviews versus checklists 33
Development of the Instrument from Conception 35

Requisite characteristics of an effective screening instrument 35
Establishing the Disorders to be Included in the Instrument

Study One 36
Relative prevalence of disorders referred to school psychologists 36
Phase One: Initial identification of disorders referred to school psychologists 36

Participants and setting 36
Procedure 36
Results and discussion 36
Phase Two: Construction and administration of questionnaire 38

Instrumentation 38
Procedure 40
Chapter summary 44
Construction and validation of a screening instrument for child and adolescent disorders 45
Study Two
Phase One: Construction of a screening instrument for child and adolescent disorders 45
Procedure, results, and discussion 45
Scoring of the Child and Adolescent Disorder Screening Instrument 46
Phase Two: Validation of the Child and Adolescent Disorder Screening Instrument 46
Stage One: Investigation of the readability of the instrument 46
Stage Two: Analysis of the agreement between responses 47
Participants 47
Setting 47
Stage Three: Clinical calibration of the Child and Adolescent Disorder Screening Instrument 54
Procedure 54
Chapter summary 56
iii
Page
Further development of the instrument – Renamed the psychprofiler 57
Wording changes 57
Scale development 58
Qualitative information 58
References 59
iv
List of Tables
Table Page
1 Range of prevalence data for the most common disorders according to the literature 21
2 Disorder categories and specific disorders identified by a selected group of experienced

teachers and school psychologists (n=15) 37
3 Referral rankings from 1 (least referred) to 8 (most referred) as Relative Prevalence

reported by school psychologists (n=72) 41
4 Percentage of school psychologists reporting one or more specific disorder referrals (n=72) 43
5 Arbitrary cutoffs for Kappa Coefficient (Landis & Koch, 1977) 51
6 Mean (and standard deviation) of Omega between the self-report, parent-report, and
teacher-report groups 53
7 Number of agreements between paediatric diagnosis, self-report, and parent-report 55
8 Readability statistics of the child and adolescent psychprofiler 57
9 Readability statistics of the adult psychprofiler 57
List of Figures
Figure Page
1 Percentage of total Relative Prevalence for each disorder category reported by

school psychologists 42
2 Frequency distribution of Omega for 5000 randomly generated cases on a four-point

ordered scale involving seven matched items 50
v
List of Abbreviations
ABS: Australian Bureau of Statistics

ACSCRS: Abbreviated Child Self-Control Rating Scale
AD: Autistic Disorder
ADDBD: Attention-Deficit and Disruptive Behaviour Disorder
ADHD: Attention-Deficit/Hyperactivity Disorder
ADHD-I: Attention-Deficit/Hyperactivity Disorder-Inattentive type
ADHD-HI: Attention-Deficit/Hyperactivity Disorder- Hyperactive Impulsive type
ADHD-C: Attention-Deficit/Hyperactivity Disorder-Combined type
AN: Anorexia Nervosa
ANOVA: Analysis of Variance
AnxD: Anxiety Disorder
APA: American Psychiatric Association
AsD: Asperger's Disorder
ASI-4: Adolescent Symptom Inventory-4
BD: Bipolar II Disorder
BN: Bulimia Nervosa
CADSI: Child and Adolescent Disorder Screening Instrument
CAS: Child Assessment Schedule
CBC: Child Behaviour Checklist (1983 and 1987 Editions)
CBCL: Child Behaviour Checklist (1991 Edition)
CD: Conduct Disorder
CGAS: Children's Global Assessment Scale
CHDS: Christchurch Health and Development Survey
CIDI: Composite International Diagnostic Interview
ComD: Communication Disorder
CSCRS: Child Self-Control Rating Scale
DD: Dysthymic Disorder
DepD: Depressive Disorder
DICA: Diagnostic Interview for Children and Adolescents
DIS: Diagnostic Interview Schedule
DISC: Diagnostic Interview Schedule for Children
DISC-IV: Diagnostic Interview Schedule for Children-Fourth Edition
DISC-P: Diagnostic Interview Schedule for Children-Parent Report
DISC-Y: Diagnostic Interview Schedule for Children-Youth Report
DMHDS: Dunedin Multidisciplinary Health and Development Study
DSM: Diagnostic and Statistical Manual of Mental Disorders
DSM-I: Diagnostic and Statistical Manual of Mental Disorders-First Edition
DSM-II: Diagnostic and Statistical Manual of Mental Disorders-Second Edition
DSM-III: Diagnostic and Statistical Manual of Mental Disorders-Third Edition
DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders-Third Edition Revised
DSM-IV: Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition
DWE: Disorder of Written Expression
ECA: Epidemiologic Catchment Area Study
ED: Eating Disorder
ELD: Expressive Language Disorder
ES: Effect Size
GAD: Generalised Anxiety Disorder
HE: Hypomanic Episode
ICD: International Statistical Classification of Diseases and Related Health Problems
ICD-10: International Statistical Classification of Diseases-Tenth Edition
IPDE: International Personality Disorder Examination
IQ: Intelligence Quotient
ISC: Interview Schedule for Children
LD: Learning Disorder
LIFE: Longitudinal Interval Follow-up Evaluation
MD: Mathematics Disorder
MRE: Mixed Receptive-Expressive Language Disorder
n: Sample Size
NCS: National Comorbidity Survey
NIMH: National Institute of Mental Health
vi
NYCLS: New York Child Longitudinal Study
NZ: New Zealand
OCD: Obsessive-Compulsive Disorder
OCHS: Ontario Child Health Study
OCHS-R: Revised Ontario Child Health Study Scales
ODD: Oppositional Defiant Disorder
p: Probability
PCPS: Primary Care Paediatric Study
PD: Phonological Disorder
PDD: Pervasive Developmental Disorder
PRCPES: Puerto Rico Child Psychiatry Epidemiologic Study
PTSD: Posttraumatic Stress Disorder
RBPC: Revised Behaviour Problem Checklist
RD: Reading Disorder
RS: Reliability Scale
SAD: Separation Anxiety Disorder
SCAN: Schedules of Clinical Assessment in Neuropsychiatry
SCRS: Self-Control Rating Scale
SD: Standard Deviation
SES: Socioeconomic Status
SPA: School Psychologists Association
SPARQ: School Psychologist's Assessment of Referrals Questionnaire
TD: Tourette's Disorder
TicD: Tic Disorder
TicD-M: Tic Disorder-Motor
TicD-V: Tic Disorder-Vocal
UCLA: University of California, Los Angeles Campus
UK: United Kingdom
USA: United States of America
vs: Versus
WACHS: Western Australian Child Health Survey
WHO: World Health Organisation
YSR: Youth Self-Report Form (of the CBCL)
vii
AUTHOR INFORMATION
psychprofiler instrument:
AUTHOR 1:
Dr Shane Langsford
Registered Psychologist
Managing Director
Psychological & Educational Consultancy Services
Suite 5 308 Hay Street Subiaco Western Australia 6008
PO Box 502 Subiaco Western Australia 6904
Phone Number: (618) 9388 8044
Facsimile Number: (618) 9388 8055
Email Address: slangsford@pecs.net.au
AUTHOR 2:
Dr Stephen Houghton
Registered Psychologist
Professor of Education
Graduate School of Education
University of Western Australia
Hampden Road, Nedlands Western Australia 6009
Phone Number: (618) 9481 2391
Email Address: steven.houghton@uwa.edu.au
AUTHOR 3:
Dr Graham Douglas
Senior Lecturer in Quantitative Methods
Graduate School of Education
University of Western Australia
Hampden Road, Nedlands Western Australia 6009
Phone Number: (618) 9380 2388
Email Address: graham.douglas@uwa.edu.au
Software Development:
AUTHOR 1:
Mr Lindsay Jamieson
Director
Strategy West Consulting
14 Tralee Way, Waterford Western Australia 6009
Phone Number: (618) 9313 3290
Email Address: jamieson@westlink.net.au
viii
Instrument Description
INSTRUMENT TITLE
psychprofiler (Langsford, Houghton, & Douglas, 2005)
INSTRUMENT COMPONENTS
The psychprofiler (Langsford, Houghton, & Douglas, 2005) is a comprehensive screening tool for the
simultaneous investigation of a large number of the most common disorders found in children, adolescents,
and adults.
The psychprofiler comprises screening criteria that closely resemble the diagnostic criteria of the Diagnostic
and Statistical Manual of Mental Disorders–Fourth Edition-Text Revision (DSM-IV-TR: American Psychiatric
Association: APA, 2000), which is the most widely used diagnostic manual in the world.
The psychprofiler consists of two separate, yet conceptually similar, instruments; namely the child and adolescent
psychprofiler (CAPP: formerly the Child and Adolescent Disorder Screening Instrument, 1999) and the adult
psychprofiler (APP).
The CAPP utilises three separate screening forms; the Self-report Form (SRF: 111 items), Parent-report
Form (PRF: 111 items), and Teacher-report Form (TRF: 91 items) for the simultaneous screening of the 20
most prevalent disorders in children and adolescents (see list below).
The CAPP is appropriate for the screening of behaviour of children and adolescents between the ages of 2
and 17 years, however, only the Parent-report and Teacher-report Forms are administered for children aged
below 10 years due to the reading level requirements of the Self-report Form.
Completion of each CAPP Form takes approximately 15 minutes and can be administered to participants in
an individual or group setting (e.g., whole class).
The APP utilises two separate screening forms; the Self-report Form (SRF: 190 items) and Observer--report
Form (PRF: 190 items) for the simultaneous screening of the 23 most prevalent disorders in adults (see list
below).
The APP is appropriate for the screening of behaviour of adults aged 18 years and older, with each Form
taking approximately 25 minutes to complete.
1
DISORDERS INCLUDED IN THE psychprofiler
Anxiety Disorders Eating Disorders
Generalised Anxiety Disorder Anorexia Nervosa
Obsessive-Compulsive Disorder Bulimia Nervosa
Panic Disorder***
Posttraumatic Stress Disorder Learning Disorders
Separation Anxiety Disorder** Disorder of Written Expression
Specific Phobia*** Mathematics Disorder
Reading Disorder
Attention-Deficit and Disruptive Behaviour Disorders
Attention-Deficit/Hyperactivity Disorder Personality Disorders
Conduct Disorder Antisocial Personality Disorder***
Oppositional Defiant Disorder
Pervasive Developmental Disorders
Communication Disorders Asperger's Disorder
Expressive Language Disorder Autistic Disorder
Mixed Receptive-Expressive Language Disorder
Phonological Disorder Tic Disorders
Motor and Vocal Tic Disorder
Depressive Disorders Tourette's Disorder
Dysthymic Disorder
Major Depressive Disorder***
*** not included in the CAPP ** not included in the APP
For a brief definition of each disorder, please see Appendix B of the Example report on pages 8-9.
COMPLETION AND SCORING PROCEDURES
All items of the APP and CAPP require responses to be made on a six-point ordered scale pertaining to the
perceived frequency of the behaviour (ie., Never, Rarely, Sometimes, Regularly, Often, or Very Often).
When calculating disorder screening scores, the items are coded as follows: Never = 0, Rarely = 0,
Sometimes = 0, Regularly = 1, Often = 1, and Very Often = 1. These values were chosen because although
many people with and without disorders may exhibit similar behaviours, it is the frequency of the behaviour
that determines whether it is of clinical significance.
A small number of exceptions to these scoring rules apply where some of the behaviours (e.g., fighting with
a weapon, stealing) are considered to be of sufficient severity that 'Sometimes' is also awarded a score of 1.
Therefore, the summation of the items within each disorder produces a screening score for that disorder,
which if exceeding the screening cutoff score, designates that the individual has been awarded a positive
screen for that disorder.
Please note that a positive screen for any of the disorders does not indicate a formal diagnosis. It merely indicates that
the individual has met sufficient criteria for a disorder to warrant further investigation by an appropriate professional.
2
VALIDITY AND RELIABILITY
In order to ensure its validity and reliability, the first version of the psychprofiler was subjected to a series of
rigorous psychometric analyses over a number of years. This process has involved validation against a large
mainstream sample (n>1000) as well as clinical calibration against individuals with formal diagnoses. These
analyses found the psychprofiler to be a highly reliable and valid screening instrument.
Furthermore, as the psychprofiler originated from Dr Langsford’s PhD thesis, its initial version has been
critically viewed by many well-regarded international experts and an indication of its stature and
differentiation from other products was provided by Associate Professor Stuart McNaughton, from the
University of Auckland.
Associate Professor McNaughton’s examiner report complemented the “careful development and testing of a
self-report instrument which overcomes previously existing problems in screening for morbidity in 20 child
and adolescent disorders”.
For full validity and clinical calibration information, please refer to the last section “Instrument Construction
from Conception”.
REPORTING
Each report generated by the psychprofiler software includes the following:
(a) Cover page

(b) Brief overview of the psychprofiler
(c) The individual’s coded data for all of the disorders, separated by respondent
(d) An indication of whether the positive screen cut-off for each disorder was met
(e) Identification of which specific items led to the positive screen cut-off being met
(f) The total number of positive screens that were reported by each respondent
(g) A Reliability Index ranging from –1 (absolute unreliability) to +1 (absolute reliability) for each
respondent
(h) A glossary of definitions of each of the disorders included within the psychprofiler
(i) Report interpretation guidelines
Each assessment using the psychprofiler allows you to:

(a) assess across a broad range of disorders if a particular ara of difficulty has not been specified
(b) provide an objective indication of whether the individual exhibits behaviours characteristic of a
suspected disorder (e.g., addressing a particular referral question)
(c) investigate differential diagnosis implications between disorders that share similar symptoms (e.g.,
anxiety, depression)
(d) assess for comorbidity and disorder clusters; which is now recognised as the norm, not the
exception
For more benefits, please see the latter section titled Ways in which the psychprofiler can improve
assessment and treatment.
The reports generated from the psychprofiler software program can be printed as hardcopies to a local or
network printer, as a Portable Document File (PDF), or as Rich Text Format (rtf).
These various file formats allow swift transfer of reports via email and permit greater importation flexibility
into other software programs such as Medical Director.
A copy of an example APP report in rtf format, including glossary of definitions and report interpretation
guidelines, is provided beginning the next page.
3
Strictly Confidential
www.pecs.net.au
adult psychprofiler
Report Form
© Langsford1, Houghton2, & Douglas3 (2005)

1
Dr Shane Langsford, Psychological & Educational Consultancy Services
2
Professor Stephen Houghton, University of Western Australia
3
Dr Graham Douglas, University of Western Australia
This report was produced using the adult psychprofiler under licence to:
PECS Laptop
4
BRIEF OUTLINE OF THE APP
The adult psychprofiler (APP) is an instrument comprising screening criteria for 23 of the most common disorders found
in adults.
The screening criteria of the APP closely resemble the diagnostic criteria listed in the Diagnostic and Statistical Manual
of Mental Disorders-Fourth Edition-Text Revision (DSM-IV-TR: American Psychiatric Association, 2000).
It is important to note that a positive screen for any of the disorders does not indicate a formal diagnosis. It merely
indicates that the individual has met sufficient criteria for a disorder to warrant further investigation by an appropriate
health professional.
APP RESULTS
Name: Justin Example Gender: Male
Address: 308 Hay Street Date of Birth: 12 May 1972

SUBIACO WA 6008
Australia
Phone: (08) 9388 8044 Age at Completion: 32

041 444 2829
Observer: Justine Example Completion Date: 23 June 2004
Disorder Positive Self Observer Positive Screen Items Met

# Indicates mutually exclusive Screen Report Report Cutoff [Self Report Items met]
screens Cutoff Score Score Attained {Observer Report Items met}
Generalised Anxiety Disorder >=1 2 2 YES [40, 54, 98, 111, 125, 126, 143, 176];
>=3 6 7 {40, 54, 98, 111, 125, 126, 143, 167,
176}
Obsessive-Compulsive Disorder >=1 0 0 NO
>=3 0 0
Panic Disorder >=1 0 0 NO
>=4 1 1
Posttraumatic Stress Disorder >=1 2 2 YES [5, 43, 109, 119, 144, 146, 176, 184];
>=3 3 4 {5, 43, 109, 119, 144, 146, 169, 176,
>=2 3 4 184, 190}
Specific Phobia =1 0 0 NO
>=3 0 0
Attention-Deficit/Hyperactivity Disorder >=6 0 0 NO
Hyperactive-Impulsive Type (#1) <6 1 2
Attention-Deficit/Hyperactivity Disorder <6 1 2 NO
Inattentive Type (#1) >=6 0 0
Attention-Deficit/Hyperactivity Disorder >=6 0 0 NO
Combined Type (#1) >=6 1 2
Conduct Disorder (#2) >=3 1 1 NO
<3 2 2
Oppositional Defiant Disorder (#2) >=4 0 0 NO
<3 1 1
<3 2 2
Expressive Language Disorder (#3) >=4 0 0 NO
<2 0 0
Mixed Receptive-Expressive Language >=4 0 0 NO
Disorder (#3) >=2 0 0
Phonological Disorder >=3 0 0 NO
Dysthymic Disorder =1 1 1 YES [47, 54, 69, 99, 114, 125, 149]; {47,
>=2 6 6 54, 69, 99, 114, 125, 149}
Major Depressive Disorder >=1 2 2 YES [21, 43, 48, 93, 127, 136, 155, 170,
>=5 7 7 189]; {21, 43, 48, 93, 127, 136, 155,
170, 190}
Anorexia Nervosa >=4 0 0 NO
Bulimia Nervosa >=4 1 1 NO
5
Disorder Positive Self Observer Positive Screen Items Met
# Indicates mutually exclusive Screen Report Report Cutoff [Self Report Items met]
screens Cutoff Score Score Attained {Observer Report Items met}
Disorder of Written Expression =1 0 0 NO
>=2 0 0
Mathematics Disorder =1 0 0 NO
>=2 0 0
Reading Disorder =1 0 0 NO
>=2 0 0
Antisocial Personality Disorder (#2) >=3 2 2 NO
Asperger's Disorder (#4) >=2 0 1 NO

>=1 0 0
<1 0 0
Autistic Disorder (#4) >=2 0 1 NO

>=1 0 0
>=1 0 0
Tic Disorder-Motor (#5) >=1 0 0 NO
<1 0 0
Tic Disorder-Vocal (#5) >=1 0 0 NO

<1 0 0
Tourette's Disorder (#5) >=1 0 0 NO
>=1 0 0
Number of Positive Screens 4 4
Self Observer
Reliability Measure (Omega Omega Report Report Reliability
Statistic) Cutoff Omega Omega Attained Comments on Reliability
Range: -1 to +1 >=0.07 -0.11 0.06 NO Neither the Self-report nor Observer-
report were above the Omega cutoff
Comments:
[No additional 'Self-Report' comments were supplied]
{Observer: Justin experienced an horrific motor accident 3 years ago. I don't believe he has ever been the same since.}
© Unauthorised use or reproduction of this report is not permitted.
6
Appendix A: APP Report Interpretation Guidelines
Disorder Column
The first column of the psychprofiler report is labelled “Disorder” and individually lists all of the disorders for
which the psychprofiler provides screening. Both Attention-Deficit/Hyperactivity Disorder (ADHD) and Tic
Disorder (TicD) have been separated into their subtypes, thereby creating a total of 26 individual disorders.
Positive Screen Cutoff Column
The second column is labelled “Positive Screen Cutoff”. This column provides the number of criterion of each
disorder that must be met in order to receive a positive screen for each respective disorder.
Disorders that have two values (e.g., Generalised Anxiety Disorder) or three (e.g., Autistic Disorder) within
the Positive Screen Cutoff column require multiple categories of criterion to be met. For instance, to be
designated a positive screen for Autistic Disorder, three separate areas of concern must be met. These three
areas, as specified by the DSM-IV-TR, include an impairment in social interaction, an impairment in
communication, and a restricted repetitive and stereotyped pattern of behaviour.
Self-Report Score Column
The “Self-Report Score” column refers to the number of screening criterion that were self-reported for each
of the disorders.
The Self Report Score for each of the disorders can be compared with the respective Positive Screen Cutoff
to see if the cutoff was exceeded, and if so, by how much.
In some instances, if the criteria for a more severe disorder has been met, then the less severe disorder(s) is
not indicated even if the criteria were also exceeded. For example, if a positive screen for Antisocial
Personality Disorder (APD) has been self-reported then a positive screen for the less severe Conduct
Disorder (CD) and/or Oppositional Defiant Disorder (ODD) is not given even if the respondent provides a Self
Report Score exceeding the Positive Screen Cutoff.
This procedure includes the distinction between the mutually exclusive screens of ADHD-HI/ADHD-I/ADHD-
C; CD/ODD/APD; ELD/MRELD; DD/MDD; AsD/AD; & TicD/TD.
Observer-Report Score Column
The “Observer-Report Score” column refers to the number of screening criterion that were reported by an
Observer on the behalf of the person being assessed. It may be interpreted in the same fashion as the Self-
Report column.
Cutoff Attained Column
If the Self-Report Score and / or the Observer-report indicates that the Positive Screen Cutoff was exceeded,
a YES is placed in this column and is shaded. Once again, mutually exclusive screens are taken into
consideration.
Please note that a YES in this column does not constitute a formal diagnosis. A YES merely indicates that
the respondent has met sufficient criteria for a disorder to warrant further investigation by a professional.
Positive Screen Items Met Column
This column lists the actual criterion that cumulatively together exceeded the cutoff culminating in a positive
screen and is separated into Self-report and Observer-report. If a paper copy was completed, a health
professional can refer back to the individual items for further validation or explanation.
Summary Statistics
“Number of Positive Screens” refers to the number of positive screens indicated by the by the Self-report and
Observer-report.
Seven items in the APP are repeated in order to provide a test of reliability. Therefore, if the “Reliability
Measure” value is greater than or equal to 0.07, then the respondent is deemed to have provided a reliable
report.
7
Appendix B: Glossary of Disorder Definitions
Anxiety Disorders:
Generalised Anxiety Disorder
Generalised Anxiety Disorder (GAD) is characterised by at least six months of persistent and excessive
anxiety and worry, occurring more days than not, about a number of events or activities.
Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder (OCD) is a condition involving recurrent obsessions (which are time
consuming and cause marked anxiety or distress) and/or by compulsions (which serve to neutralise anxiety).
Panic Disorder
Panic Disorder (PanD) is the presence of recurrent, unexpected Panic Attacks, followed by at least one
month of persistent concern about having another Panic Attack.
A Panic Attack is a discrete period of intense fear or discomfort in the absence of real danger that is
accompanied by a number of somatic or cognitive symptoms such as shortness of breath, palpitations, chest
pain or discomfort, and fear of “going crazy” or losing control.
Posttraumatic Stress Disorder

Posttraumatic Stress Disorder is the development of symptoms involving the re-experiencing of an extremely
traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with
the trauma.
Separation Anxiety Disorder

Separation Anxiety Disorder is characterised by developmentally inappropriate and excessive anxiety
concerning separation from home or from those to whom the child is attached.
Specific Phobia
Specific Phobia is characterised by clinically significant and persistent anxiety provoked by exposure to a
specific feared object or situation.
Attention-Deficit and Disruptive Behaviour Disorders:

Attention-Deficit/Hyperactivity Disorder
The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity that is
more frequent and severe than is typically observed in individuals at a comparable level of development.
Conduct Disorder
Conduct Disorder (CD) is a repetitive and persistent pattern of behaviour in which the basic rights of others,
or major age-appropriate societal norms or rules are violated.
Oppositional Defiant Disorder:

Oppositional Defiant Disorder (ODD) is a recurrent pattern of negativistic, defiant, disobedient, and hostile
behaviour toward authority figures that persists for at least six months.
Communication Disorders:
Expressive Language Disorder:
The essential feature of Expressive Language Disorder (ELD) is an impairment in expressive language
development as demonstrated by scores on standardised individually administered measures of expressive
language development substantially below those obtained from standardised measures of both nonverbal
intellectual capacity and receptive language development.
Mixed Receptive-Expressive Language Disorder:

Mixed Receptive-Expressive Language Disorder (MRELD) is characterised by an impairment in both
receptive and expressive language development as demonstrated by scores on standardised individually
administered measures of both receptive and expressive language development that are substantially below
those obtained from standardised measures of nonverbal intellectual capacity.
Phonological Disorder:
Phonological Disorder (PD) is a failure to use developmentally expected speech sounds that are appropriate
for the individual's age and dialect.
8
Depressive Disorders:
Dysthymic Disorder:
Dysthymic Disorder (DD) is chronically depressed mood that occurs for most of the day more days than not
for a period of at least two years.
Major Depressive Disorder:

Major Depressive Disorder (MDD) is a clinical course that is characterised by one or more Major Depressive
Episodes.
A Major Depressive Episode is a period of at least two weeks during which there is either depressed mood
or the loss of interest or pleasure in nearly all activities.
Eating Disorders:
Anorexia Nervosa:
The essential features of Anorexia Nervosa (AN) are that the individual refuses to maintain a minimally
normal body weight, is intensely afraid of gaining weight, and exhibits a significant disturbance in the
perception of the shape and size of his or her body.
Bulimia Nervosa:
Bulimia Nervosa (BN) involves binge eating and inappropriate compensatory methods to prevent weight
gain, and a self-evaluation that is excessively influenced by body shape and weight.
Learning Disorders:
Disorder of Written Expression:
Disorder of Written Expression (DWE) pertains to where writing skills (as measured by an individually
administered standardised test or functional assessment of writing skills) fall substantially below those
expected given the individual's chronological age, measured intelligence, and age-appropriate education.
Mathematics Disorder:
The essential feature of Mathematics Disorder (MD) is mathematical ability (as measured by individually
administered standardised tests of mathematical calculation or reasoning) that falls substantially below that
expected given the individual's chronological age, measured intelligence, and age-appropriate education.
Reading Disorder:
A Reading Disorder (RD) is where reading achievement (i.e., reading accuracy, speed, or comprehension as
measured by individually administered standardised tests) falls substantially below that expected given the
individual's chronological age, measured intelligence, and age-appropriate education.
Pervasive Developmental Disorders:

Asperger’s Disorder:
The essential features of Asperger’s Disorder (AsD) are severe and sustained impairment in social
interaction and the development of restricted, repetitive patterns of behaviour, interests, and activities.
Autistic Disorder:
Autistic Disorder (AD) involves the presence of markedly abnormal or impaired development in social
interaction and communication, and a markedly restricted repertoire of activity and interests.
Personality Disorders:
Antisocial Personality Disorder:
Antisocial Personality Disorder (APD) is characterised by a pervasive pattern of disregard for, and violation
of, the rights of others.
Tic Disorders:
Tic Disorder- Motor
A Tic Disorder- Motor (TicD-M) is a sudden, rapid, recurrent, nonrhythmic stereotyped motor movement such
as eye blinking, neck jerking, shoulder shrugging, facial contortion, and twirling when walking.
Tic Disorder-Vocal
A Tic Disorder- Vocal (TicD-V) is a sudden, rapid, recurrent, meaningless sounds such as throat clearing,
grunting, sniffing, snorting, and spontaneous expression of single words or phrases.
Tourette’s Disorder:
Tourette’s Disorder (TD) refers to where there are multiple motor tics and one or more vocal tics.
9
UTILISATION OPTIONS
The psychprofiler allows assessments to be conducted using a traditional pencil-and-paper checklist approach
or as a computer administered task with the items being presented “on-screen”.
Pencil-and-Paper Checklist:
The pencil-and-paper checklist approach involves the Health Professional providing their client/patient with
the psychprofiler Forms who disseminates them to the respective respondents (e.g., Teacher, Observer) and
coordinates the return of the completed Forms to the Health Professional.
If the Health Professional has purchased a psychprofiler software licence, the data of the completed Forms
can be quickly entered by the Health Professional, or designated staff member, using the “Enter Responses”
mode of the psychprofiler software program.
Data entry, scoring, analysis, and report generation using this approach is complete in less than 10 minutes.
In the event that a Health Professional does not have a psychprofiler software licence, the relevant Forms can
be obtained from Psychological & Educational Consultancy Services (PECS) who will provide them to the
Health Professional or directly to their client/patient.
Once completed, the Forms are returned to PECS where the data is entered, scored, analysed and the
report sent to the respective Health Professional within 2 working days of receiving the Forms.
psychprofiler Software Program:

The psychprofiler computer software program allows a client/patient to complete the items on-screen at the
Health Professional’s office (or central agency such as a Division of General Practice).
Each item is presented on-screen, to which the client/patient uses the computer mouse to choose their
response from 1 of the 6 frequency options within the Likert scale (anchored by Never to Very Often).
As each Form is completed, the data is encrypted and stored within the psychprofiler’s data reservoir ready for
analysis once all of the respondents have completed their respective Form.
Multiple security safeguards are in place to ensure that a patient/client cannot access the results of another
patient/client who has previously completed the psychprofiler.
The psychprofiler Software Program has been extensively tested and declared fully compatible with Windows
XP, Windows 2000, and Windows 98 Second Edition.
Online Versions of the psychprofiler:

A HTML version of each Form is located at www.pecs.net.au/psychprofileronline, which allows the
client/patient to access and complete the Forms from any Internet-connected computer in the world.
Each Form is password protected, allowing access only to client/patients who have obtained the “login and
password” details from their Health Professional.
The data for each completed Form is automatically encrypted and transferred to the PECS workstation
where it is scored, analysed and the report sent to the designated Health Professional within 2 working days
of receiving the data.
These various psychprofiler options are currently being utilised by a large number of Clinical Psychologists,
General Practitioners, Paediatricians, Psychiatrists, and School Psychologists throughout Australia.
10
WAYS IN WHICH THE psychprofiler CAN IMPROVE ASSESSMENT AND TREATMENT
The psychprofiler has successfully addressed many of the shortcomings of existing instruments and
subsequently led to an improvement in accurate identification and treatment of disorders in children,
adolescents, and adults.
Increased Early Identification and Intervention

An accessible and affordable screening assessment can improve the early identification of disorders which is
crucial in the prevention of the development of further mental health problems.
For example, disorders of depression have been shown to predispose an individual to a variety of other
disorders (e.g., anxiety disorders, and eating disorders), as well as problems in the areas of school drop-out,
unemployment, drug involvement, delinquent behaviour, and criminal conviction.
Provision of Objective and Reliable Data

The psychprofiler is based on recognised diagnostic criteria (DSM-IV-TR), incorporates multiple respondents,
and has been rigorously validated thus reducing the subjectivity that often plagues other instruments.
Optimises the Efficiency of Clinical Interviewing

The psychprofiler can optimise the efficiency of clinical interviewing and information gathering by being
completed prior to the first consultation with the health professional.
If advised when making the appointment for the first consultation, the client / patient can utilise one of the
available methods and have the report forwarded to the health professional prior to the first consultation.
This enables the health professional to have an accurate psychological profile of the individual, and
therefore, cursory validation of the results may be all that is needed rather than time consuming in-depth
interviewing.
Assistance with Differential Diagnosis Implications

Due to the psychprofiler containing DSM-IV-TR criteria for a large number of disorders, it can abet more
accurate diagnosis practices by differentiating between disparate disorders (e.g., anxiety, depression) that
share similar characteristic behaviours / symptomology (e.g., difficulty sleeping, poor attention).
Assistance with Comorbidity Implications

The psychprofiler can be used to investigate for comorbidity, which is extremely important because the
majority of children and adults with a disorder have multiple disorders.
Therefore, psychprofiler can aid in the identification and intervention provision for the more covert comorbid
disorders that would under normal circumstances remain unnoticed and untreated. Despite these comorbid
disorders being less overt, appropriate treatment is still necessary.
Provision of Important Self-Report Information

Unlike many of the existing instruments, the psychprofiler incorporates self-report information. Self-report
information can contribute greatly to an understanding of child and adolescent disorders, since it has been
shown that the experience of children is often different to that reported by parents, teachers, and clinicians.
This is particularly so for disorders that often do not have easily observable behavioural manifestations, such
as anxiety and depression.
11
Improved Communication, Especially With Regards to Sensitive Issues
The psychprofiler is already being successfully used by general practitioners, paediatricians, psychiatrists,
psychologists and school psychologists.
These health professionals declare that completion of the psychprofiler helps open up the lines of
communication with the individual, especially when dealing with sensitive issues.
Improved Identification of Disorders in Mainstream Individuals

Over the past 25 years, results of a large number of studies have proven remarkably convergent in that at
least 20% of the population present with one or more disorder. Unfortunately, this research has also
consistently indicated that only 16-21% of these children and adults with a disorder are identified and receive
appropriate intervention.
Therefore, due to the APP and CAPP simultaneously screening for 23 disorders, and 20 disorders,
respectively, they can successfully screen mainstream individuals (e.g., whole grades, whole schools, prison
populations) for disorders which would normally go unidentified.
Evaluating the Effectiveness of Intervention

The APP provides an excellent profile of the adult due to it providing 190 individual pieces of behavioural
information (ie the number of items) from 2 separate informants (i.e., self, observer). Similarly, the CAPP
provides an excellent profile of the child due to it providing 111 individual pieces of behavioural information
(ie the number of items) from 3 separate informants (i.e., child, parent, teacher).
Therefore, the effectiveness of intervention can easily be monitored by having the informants complete the
APP or CAPP before, during, and after intervention.
Improving Accessibility to Assessment Services

Due to the psychprofiler being available by post, provided as a stand-alone software application, or completed
online, the psychprofiler has proven to be very important instruments in rural and remote areas.
Improving Referral Practises

Due to the psychprofiler providing a comprehensive profile of the individual, the results enable a health
professional to refer to a third party (e.g., medical specialist, psychologist) whom they feel is best suited to
the individual case.
For example, a health professional may prefer to refer an individual with comorbid depression and eating
disorders to a different third party than if the individual had comorbid depression, anxiety, and eating
disorders.
12
COMPETING INSTRUMENTS
The psychprofiler has been viewed by many well-regarded experts and an indication of its stature and
differentiation from other products was provided in one of the PhD examiners reports.
Associate Professor Stuart McNaughton, from the University of Auckland, complemented the “careful
development and testing of a self-report instrument (ACASI) which overcomes previously existing problems
in screening for morbidity in 20 child and adolescent disorders”.
(The ACASI was the first version of the CAPP, however, subsequent psychometric testing over a
number of years have led to further improvements and ultimately name changes)
As noted by Professor McNaughton, the CAPP is an extremely valuable instrument because it addresses a
number of short-comings in the available screening instruments. For example, the CAPP contains items
based on the DSM-IV-TR diagnostic criteria for 20 of the most commonly referred disorders. Many of the
available instruments do not utilise recognised diagnostic criteria, and investigate too few disorders (e.g 1-4),
to be considered an effective global disorder screening tool.
The CAPP incorporates three separate perspectives; namely self-report, parent-report, and teacher-report.
Most of the existing instruments rely solely on adult ratings and hence do not collect important self-report
information. Self-report can contribute greatly to an understanding of child and adolescent disorders, since it
has been shown that the experience of children is not identical to the attributions of their symptoms by
parents, teachers, and clinicians. This is particularly so for signs and symptoms that do not only describe
observable behavioural manifestations, but are more closely linked to internal emotional states, such as
anxiety and depression.
Many of the available instruments have not undergone sufficient psychometric testing, especially the
validation against clinical judgement. In order to ensure its validity and reliability, the CAPP has been
subjected to a series of rigorous psychometric analyses over the past 8 years. This process has involved
validation against a large mainstream sample (n>800) as well as clinical calibration against children and
adolescents with formal paediatric diagnoses. These analyses found all three of the CAPP Forms to be
highly reliable and valid for the screening of disorders in children and adolescents.
None of the available global screening instruments utilise scoring software which will make large-scale
screening affordable to groups such as whole grades or entire schools.
13
THEORETICAL BASIS OF THE INSTRUMENT
The initial psychprofiler instrument was developed for the screening of children and adolescents, therefore, the
following Theoretical Basis of the Instrument and subsequent description of the Development of the
Instrument since Conception focuses very much on the child and adolescent population. The adult version of
the psychprofiler is unmistakably a theoretically, conceptually, and developmentally similar instrument to the
child and adolescent psychprofiler.
INTRODUCTION
Given the serious consequences associated with many child and adolescent disorders (i.e., specific
individual disorders), knowledge about the prevalence of disorders within this population is important
(Lewinsohn, Hops, Roberts, Seely, & Andrews, 1993). For example, disorders of depression have been
shown to predict problems in the areas of school drop-out, unemployment, drug involvement, delinquent
behaviour, and criminal conviction (Carlson & Stroeber, 1979; Chiles, Miller, & Cox, 1980; Kandel & Davies,
1986; Newcomb & Bentler, 1988; Paton, Kessler, & Kandel, 1977). Therefore, it is not surprising that a fairly
large number of prevalence studies have been conducted. Unfortunately, many of the studies that have
attempted to investigate prevalence have produced remarkable inconsistencies. One of the major reasons
for this variation in prevalence studies is the inconsistency in the way in which diagnostic criteria are used,
and hence, the confusion surrounding what actually constitutes a disorder.
Definition of disorder:
There is neither a clear definition of the term disorder that is universally satisfactory, nor a uniformly agreed
upon method for ascertaining the existence of a disorder. From a medical point of view, disorders are
perceived of as medical diseases, and the separate existence of disorders can be established by clinical
description, epidemiology, premorbid personality, course, family history, laboratory findings, and response to
treatment. More relevant to psychological and behavioural domains is construct validation including the
description of diverse developmental pathways to ultimate symptom constructs. Without an agreed upon
definition of disorder, the field appears to be moving on by using reliable criterion sets (Clarkin & Kendall,
1992; Hinkle, 1994; Kaslow, 1993; Wakefield, 1992) such as those provided in the widely used Diagnostic
and Statistical Manual of Mental Disorders published by the American Psychiatric Association (DSM I-IV:
APA, 1951-1994).
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV: APA, 1994, p. xxi) conceptualises
disorder as:
a clinically significant behavioural or psychological syndrome or pattern that occurs in an

individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e.,
impairment in one or more important areas of functioning) or with a significantly increased risk of
suffering death, pain, disability, or an important loss of freedom.
Despite this lengthy and comprehensive definition, the DSM-IV (APA, 1994, p. xxi) acknowledges that
"although this manual provides a classification of mental disorders, it must be admitted that no definition
adequately specifies precise boundaries for the concept of mental disorder". This lack of confidence in a
definition of disorder is of particular importance to the DSM's conceptual structure because according to
Wakefield (1992, p. 232) the DSM is "designed to be an atheoretical manual that is acceptable to clinicians
and researchers of many theoretical persuasions".
Methodological inconsistencies:
Another of the major reasons for the inconsistency of results across studies is due to the different
methodologies employed. Such studies have used a wide array of diagnostic criteria (many of which are now
obsolete), including semistructured interviews and behavioural checklists. Understandably, the different
instrumentation is likely to produce varying results, with the semistructured interview consistently being found
to report the lower prevalence estimates (McGee et al., 1990). Furthermore, due to the variation in time
commitments associated with the different diagnostic criteria, many studies investigating the prevalence of
child and adolescent disorder (i.e., the collective grouping of individual disorders to include all children and
adolescents with at least one disorder) have been forced to limit the number of disorders investigated
(McGee et al., 1990). Therefore, many estimates of the prevalence of child and adolescent disorder have
14
been made based on the investigation of only a small number of disorders. It seems likely therefore, that the
prevalence of child and adolescent disorder is greater than that predicted on the basis of only three or four
disorders.
In addition, many of the diagnostic methodologies have used parents and teachers as the source of
information for assessing disorder in an individual. Obviously, adult perceptions will continue to be important,
because adults are the source of child referrals. However, although traditionally child and adolescent's
ratings of their own behaviour have been viewed as suspect (Hughes, 1988), their perceptions have now
come to be considered valuable in their own right (Angold, 1996; Finch & Rogers, 1984; Mash & Terdal,
1988; Rohrbeck, Azar, & Wagner, 1991).
There are several reasons why the child or adolescent's self-report of his or her own behaviour might be
useful. First, adult perceptions may be misperceptions, therefore, it is important to illuminate the unique
information gained from a self-report measure, as compared to an adult rating of the child's behaviour.
Second, unlike parent and teacher-reports, self-reports are more likely to reflect behaviour across all
situations, not just the home or classroom (Beitchman & Corradini, 1988; Karoly, 1981). For example, parent-
reports can be biased due to their subjectivity (Achenbach & Edelbrock, 1978; Barkley, 1981), whereas
teacher-reports may reflect a child's behaviour in only one structured situation (e.g., mathematics class), or
may reflect an idiosyncratic teacher-pupil relationship (Rohrbeck et al., 1991). Third, to exclude self-report
perspectives may unnecessarily narrow the focus of interventions to observable behaviours and external
contingencies. This could easily cause an under-reporting of symptoms that are more closely linked to
internal emotional states, such as anxiety and depression (Weinstein, Noam, Grimes, Stone, & Schwab-
Stone, 1990).
Another reason for the variation in results across prevalence studies is due to the differing characteristics of
the samples. In the majority of cases, population prevalence estimates have been extrapolated from clinic
samples. Only community samples reveal the true pattern of disorders, free from any self-selection into, or
referral within the health care system. Furthermore, the age, gender, and number of participants have varied
markedly, with many sample sizes often being too small to yield stable results (Lewinsohn et al., 1993).
The majority of prevalence studies have been conducted with adolescent participants (aged 13-17 years),
and therefore information about disorder in children (aged 6-12 years) is sparse. The data available suggest
that there is a slight rise in the rate of child and adolescent disorder between late childhood and early
adolescence (Rutter, Tizard, Yule, Graham, & Whitmore, 1976). In accord, Tongue (1998) believes that the
prevalence of child and adolescent disorder increases by 3-4% after puberty. Therefore, studies that have
extrapolated the prevalence rates of childhood disorders from a sample of adolescents may well be over-
reporting. However, Rutter et al. (1976) found approximately 40% of disorders seen in adolescence had
persisted since childhood and the rest had newly developed during early adolescence. Similarly, up to one
half of adult cases of obsessive-compulsive disorder (OCD) have been found to begin by the age of 15 years
(Rapoport, 1986) and patients with eating disorders (EDs) typically report that their symptoms began during
adolescence (Garfinkel & Garner, 1982). These findings highlight the need for future prevalence surveys to
cover a wide age range of children and adolescents in order to extend our knowledge of the distribution,
correlates, and typical age of onset of disorders (Offord, 1985). This developmental aspect needs to be
addressed because the data resulting from such studies enable population trends to be accurately predicted,
thereby making it feasible to plan future service needs in a more rational fashion.
The study of gender differences has been identified as an important area of child and adolescent disorder
research because it is hoped that this type of research may lead eventually to a better understanding of the
nature of disorders in males and females, concerning both similarities and differences. To date, studies have
indicated that almost all disorders (except disorders such as anxiety, depression, and eating) are more
common in males than in females. For example, learning disorders (LDs) have been found to be more
common among males than females, with ratios ranging from 3:1 to 15:1 (Finucci & Childs, 1981). For this
reason, the majority of research samples have been all male (or predominantly male). Because studies
frequently focus on male participants very little is known about females and even less about gender
differences (Vogel, 1990). Knowledge of how males and females differ might lead to the development of
more appropriate screening and identification procedures and effective instructional strategies for females as
distinct from those used with males.
Other methodological considerations exist because the prevalence of child and adolescent disorder has
been found to be greater in low SES areas than in high SES areas (Bruce, Takeuchi, & Leaf, 1991; Holzer et
al., 1986; Kessler et al., 1994; Tongue, 1998; Weich, Churchill, Lewis, & Mann, 1997; Williams, Takeuchi, &
Adair, 1992). Furthermore, SES has been found to be associated not only with the onset, but also with the
course of a disorder (Kessler et al., 1994). Unfortunately, almost all of the research pertaining to SES
15
comprises adult participants. It is merely presumed that SES exerts the same influence on child and
adolescent disorders.
Prevalence of child and adolescent disorder:

As a result of these differences in methodology, studies that have investigated the prevalence of child and
adolescent disorder, have produced markedly varied results. Regier and Robins (1991) reported that the
prevalence rates of child and adolescent disorder have been found to range from 11% to 57%. Despite
estimates of prevalence reaching as high as 57%, a review of 25 studies (published between 1928 and
1974) by Gould, Wunsch-Hitzig, and Dohrenwend (1981) led the authors to estimate the prevalence of child
and adolescent disorder to be 11.8%. However, more recent studies have consistently produced prevalence
rates in excess of 20% (e.g., Fergusson, Horwood, & Lynskey, 1993; McGee et al., 1990) with some
reporting prevalence rates as high as 48% (Kessler et al., 1994). Similar variations are also reported for
individual disorders. For example, the prevalence of attention-deficit/hyperactivity disorder (ADHD) has been
reported from as low as 1% (McGee, Feehan, Williams, & Anderson, 1992) to as high as 13% (Velez,
Johnson, & Cohen, 1989).
Although many of the studies that have reported the higher prevalence findings have been strongly criticised,
the true prevalence rate of child and adolescent disorder may in fact be higher than that being commonly
reported. A study by Costello et al. (1988) compared the prevalence rate of disorder diagnosed using a
structured interview (22%) with that identified by paediatricians (5.7%). Furthermore, Costello et al. (1988)
suggested that there exists among children and adolescents a large pool of disorders, and that these are
largely unrecognised even by physicians who see the children regularly. Similarly, Prizant, et al. (1990, p.
186) stated that "current experience in our clinical setting and that reported in other settings for children with
emotional and behavioural disorders (e.g., Cantwell, 1987) indicate that many children and adolescents with
more subtle forms of disorder often are not identified". Therefore, it appears that the majority of children and
adolescents with disorder are failing to be identified (Anderson, Williams, McGee, & Silva, 1987; Costello,
1989b; Costello et al., 1988; Offord et al., 1987). This is commensurate with the findings of studies from
several industrialised countries which indicate that only a small proportion of children and adolescents with
disorder actually receive specialist treatment (Burd, Kerbeshian, Cook, Bornhoeft, & Fisher, 1988; Costello,
et al., 1988; Costello & Janiszewski, 1990; Offord et al., 1987). For example, Offord et al. (1987) found
evidence of a disorder in 18.1% of children, but of these, only 6.5% had received any services from mental
health or social service providers. Similarly, a study in New Zealand (NZ) reported that of the children and
adolescents presenting with a disorder, only 21% were in contact with any service for their problems.
(Fergusson et al., 1993).
This low incidence of identification, and hence low rate of treatment, may simply be due to the disorder(s)
going undetected, or sometimes the result of a more overt disorder masking the more subtle disorders. For
example, children with significant behavioural disorders (e.g., conduct disorder [CD]) who also experience a
communication disorder (ComD) from early in the school years are often not identified as having a ComD.
They may be placed in classes for the behaviourally disordered or emotionally disturbed, and because
symptomatology of emotional and behavioural disorders are most often the primary concern, more subtle
communication problems that may be involved directly in the development or perpetuation of the behavioural
and/or emotional disturbance may be overlooked (Prizant et al., 1990). Similarly, Burd, Kauffman, and
Kerbeshian (1992) found that less than 25% of children with Tourette's disorder (TD) had their LDs
diagnosed in a school setting. Thus, ongoing identification is essential to provide appropriate services for
children and adolescents with disorders that may simply go undetected during the school years or those with
disorders that are masked by a more overt disorder.
Comorbidity among disorders:

In recent years, there has been a renewed interest and re-emphasis on the comorbidity among disorders. At
its simplest, comorbidity is the occurrence at one point in time of two or more disorders (Clarkin & Kendall,
1992). The main purposes of collecting comorbidity data are to further our understanding of the disorders, to
alert teachers and psychologists to possible complications, and to provide indications for treatment,
prognosis, and educational service delivery (Rachman, 1991). Psychological analyses of comorbidity would
serve each of these aims, and also open the way for more precise analyses of the relationship between two
or more disorders. It would also provide a tool for determining whether or not any reported co-occurrence is
a static association or a dynamic connection (Rachman, 1991).
Evidence of comorbidity among varying disorders has been well documented. Beitchmen, Nair, Clegg, and
Patel (1986) conducted a study of five-year-old kindergarten children who were assessed for speech and
language disorders. They found 11% had speech and language disorders, and of these, 48.7% presented
with a disorder in addition to the speech and language disorder. In studies that have directly assessed the
relationship between IQ and academic achievement, LDs have been found to occur in about 50% of children
16
with TD (Bornstein, Carroll, & King, 1985; Burd et al., 1988; Golden, 1984; Hagin, Beecher, Pagano, &
Kreeger, 1982; Hagin & Kugler, 1988; Joschko & Rourke, 1982). Similarly, there is a higher incidence of
OCD in individuals with TD, with estimates ranging from approximately 35% to 50% (APA, 1994).
On the basis of prevalence studies and the results from specific populations, comorbidity among disorders
can be considered extensive. Comorbidity has been found to be so extensive that some researchers (e.g.,
Blashfield, 1990; Brown & Barlow, 1992) have begun to question the assumption that the DSM-III-R (APA,
1987) has definite, discrete, and separate entities. This extensive comorbidity can be interpreted as
suggesting that a dimensional approach to classification, rather than the categorical approach, might be the
more parsimonious (Blashfield, 1990; Brown & Barlow, 1992). Therefore, it has been suggested that in
addition to the simple determination of the co-occurrence of two disorders, attention should be given to the
"psychological connectedness" (Rachman, 1991, p. 461) of the comorbid disorders and to consideration of
"comorbid symptom clusters" (Clarkin & Kendall, 1992, p. 904).
In light of the Lewinsohn et al. (1993, p. 142) finding that "the degree of comorbidity between all of the major
DSM-III-R disorders was found to be substantial", it is feasible that there is a single underlying factor
common to all disorders. Researchers who have already attempted analyses from this theoretical standpoint
include Beitchman (1985), Baker and Cantwell (1987b), and Baltaxe and Simmons (1988b). Unfortunately, to
date, all research investigating the possibility of an underlying factor common to all disorders has proved
inconclusive. Variables that have been examined include social class, low IQ, significant hearing loss,
organic brain damage, adverse family conditions, low SES, mental retardation, marked hearing loss, brain
damage, parental mental illness, family discord, and significant stress in childhood.
Chapter summary:
Although a large number of prevalence studies have been conducted, to date there appears to have been
very few investigations of disorder in mainstream children and adolescents in Australia. Of the few that have
been conducted, the majority have been plagued by a number of methodological problems which has
resulted in inconsistent findings.
In order to further our knowledge of disorder, research utilising an instrument based on currently accepted
diagnostic criteria, covering a wide array of disorders, with a large sample of mainstream children and
adolescents is required. The sample must represent both genders, a wide age range, and varying SES
areas. This will allow a more accurate identification of the true prevalence rate of child and adolescent
disorder, as well as the true prevalence rates of individual disorders. Moreover, research of this type will be
able to explore comorbidity among the disorders and determine whether one underlying factor may be
common to all disorders.
Furthermore, the utilisation of a reliable and valid instrument comprising a large number of disorders could
be used in the early screening of young children for disorders. The early identification of disorders and the
subsequent provision of appropriate intervention forms a vital step in any treatment program (Newman et al.,
1996).
17
LITERATURE REVIEW
Prevalence of child and adolescent disorder:

There exists within the population a large number of children and adolescents with a disorder. Just how
many, we can not be sure, yet there can be no doubt they constitute a significant minority. Studies that have
attempted to pinpoint the prevalence of child and adolescent disorder (i.e., the collective grouping of
individual disorders to include all children and adolescents with at least one disorder), have produced
markedly varied results. Regier and Robins (1991) reported that the prevalence rates of child and adolescent
disorder have been found to range from 11% to 57%. Despite estimates of prevalence reaching as high as
57%, a review of 25 studies (published between 1928 and 1974) by Gould, Wunsch-Hitzig, and Dohrenwend
(1981) led the authors to estimate the prevalence of child and adolescent disorder to be 11.8%. However,
more recent studies have consistently produced prevalence rates in excess of 20% (e.g., Fergusson,
Horwood, & Lynskey, 1993; McGee et al., 1990) with some reporting prevalence rates as high as 48%
(Kessler et al., 1994). Similar variations are also reported for child and adolescent disorders (i.e., specific
individual disorders). For example, the prevalence of attention-deficit/hyperactivity disorder (ADHD) has been
reported from as low as 1% (McGee, Feehan, Williams, & Anderson, 1992) to as high as 13% (Velez,
Johnson, & Cohen, 1989).
Although many of the studies that have reported the higher prevalence findings have been strongly criticised,
the true prevalence rate of child and adolescent disorder may in fact be higher than that being commonly
reported. A study by Costello et al. (1988) compared the prevalence rate of disorder diagnosed using a
structured interview (22%) with that identified by paediatricians (5.7%). Furthermore, Costello et al. (1988)
suggested that there exists among children and adolescents a large pool of disorders, and that these are
largely unrecognised even by physicians who see the children regularly. Similarly, Prizant, et al. (1990, p.
186) stated that "current experience in our clinical setting and that reported in other settings for children with
emotional and behavioural disorders (e.g., Cantwell, 1987) indicate that many children and adolescents with
more subtle forms of disorder often are not identified".
Therefore, it appears that the majority of children and adolescents with disorder are failing to be identified
(Anderson, Williams, McGee, & Silva, 1987; Costello, 1989b; Costello et al., 1988; Offord et al., 1987). This
is commensurate with the findings of studies from several industrialised countries which indicate that only a
small proportion of children and adolescents with disorder actually receive specialist treatment (Burd,
Kerbeshian, Cook, Bornhoeft, & Fisher, 1988; Costello, et al., 1988; Costello & Janiszewski, 1990; Offord et
al., 1987). For example, Offord et al. (1987) found evidence of a disorder in 18.1% of children, but of these,
only 6.5% had received any services from mental health or social service providers. Similarly, a study in New
Zealand (NZ) reported that of the children and adolescents presenting with a disorder, only 21% were in
contact with any service for their problems. (Fergusson et al., 1993).
Given the serious consequences associated with many child and adolescent disorders (i.e., specific
individual disorders), the early, and accurate, identification of disorders within this population is extremely
important (Lewinsohn, Hops, Roberts, Seely, & Andrews, 1993). For example, disorders of depression have
been shown to predict problems in the areas of school drop-out, unemployment, drug involvement,
delinquent behaviour, and criminal conviction (Carlson & Stroeber, 1979; Chiles, Miller, & Cox, 1980; Kandel
& Davies, 1986; Newcomb & Bentler, 1988; Paton, Kessler, & Kandel, 1977).
Without doubt, the best way to improve the early identification of children and adolescents with disorders,
would be to conduct large-scale screening using a clinically calibrated instrument containing a large number
of the most prevalent disorders. Obviously the early identification of a disorder would subsequently lead to
early intervention thus considerably improving the prognosis.
The methodological quality of a prevalence investigation depends on three principal criteria: (i) the degree to
which the study's sample is representative of the population of children and adolescents as a whole
(Brandenberg, Friedman, & Silver, 1990; Doll, 1996; Fleming & Offord, 1990); (ii) consent rates for
participation being at or above 70% (Fleming & Offord, 1990); and (iii) the reliable distinction between cases
and noncases of disorders. This distinction can only be made when there is a standard diagnostic protocol
defining what is, and is not, a disorder; and when there is a reliable means for determining when cases meet
the criteria (Doll, 1996).
With the introduction of the DSM diagnostic system (DSM-I, 1951) several prevalence studies were
undertaken in the 1960s. However, the findings for the prevalence of child and adolescent disorder varied
widely, with results ranging from 11% to 57% (Regier & Robins, 1991). Despite estimates of prevalence
reaching as high as 57%, a review of 25 studies (published 1928 through 1974) by Gould et al. (1981) led
them to estimate the prevalence of child and adolescent disorder to be 11.8%.
18
Setting aside any reliability problems associated with the DSM-I, early studies also suffered from significant
methodological deficits, including problems with sampling procedures. Early prevalence survey estimates
were frequently derived from child and adolescent samples obtained exclusively from medical centres, which
failed to account for the degree to which the samples represented the community at large (Doll, 1996). Only
community samples reveal the true pattern of disorder, free from any self-selection into, or referral within the
health care system (Doll, 1996).
Furthermore, very few of these early surveys, which attempted to determine the prevalence of child and
adolescent disorder, employed questionnaires validated against clinical judgement to ascertain the presence
and degree of the disorder (Offord et al., 1987). Of the studies that have used clinically validated
instruments, many have produced similar results, despite the various types and definition of disorder. For
instance, Lagner et al. (1974) reported that 17.5% of a random sample presented with a disorder; Graham
and Rutter (1973) reported that 21.0% of their 14 to 15 year-old sample presented with a disorder; Rutter,
Cox, Tupling, Berger, and Yale (1975) found a disorder in 25.4% of their Inner London Borough sample; and
Verhulst, Berden, and Sanders-Woudstra (1985) reported that 26.0% presented with a moderate to severe
disorder.
More recent large-scale studies have suggested that the prevalence of child and adolescent disorder is
proliferating widely, and in what might almost be deemed an epidemic pattern (Doll, 1996). However, serious
methodological flaws in most of the studies published prior to 1986 preclude direct comparisons, and make it
extremely difficult to determine whether the most recent figures reflect an increase in the actual prevalence
of child and adolescent disorder or merely an increase in the accuracy with which disorders are identified
(Doll, 1996).
One of the earliest large-scale studies to be published post-1986 was the Ontario Child Health Study
(OCHS: Offord et al., 1987. The OCHS sample comprised 2674 children and adolescents aged between 4
and 16 years. Four scales were utilised, which consisted of items selected from the Child Behaviour
Checklist (CBC: Achenbach & Edelbrock, 1983), to operationalise DSM-III (APA, 1980) criteria for four
disorders: CD, hyperactivity, emotional disorder (anxiety and depression), and somatisisation (sickliness
without cause). The scales were administered to the parents and teachers of all children below the age of 12
years, and to the children and parents of 12 to 16 year-olds. Findings revealed that among children and
adolescents 4 to 16 years of age, the overall six-month prevalence rate of one or more of these four
disorders was 18.1% (Offord et al., 1987).
Although the reported prevalence value of 18.1% is below the majority of the earlier studies cited, it should
be noted that the Offord et al. (1987) study only investigated the existence of four DSM-III disorders.
Presumably, an evaluation that also included other common disorders would have led to an even higher
prevalence rate (Greenberg, 1997). In addition, the rate of emotional disorder (anxiety and depression) may
have been deflated due to the diagnostic information for the 4 to 12 year age group being provided by the
parents and teachers, without the input of the child (Edelbrock, Costello, Dulcan, Kalas, & Conover, 1985).
Furthermore, studies such as that of Offord et al. (1987) which have utilised interviews have tended to
produce lower estimates than written instrumentation due to social desirability (McGee et al., 1990).
In Pittsburgh, United States of America (USA), the National Institute of Mental Health (NIMH) Primary Care
Pediatric Study (PCPS: Costello, 1989b) investigated the prevalence of disorder in 789 children (aged 7-11
years) who were visiting their primary care paediatrician for a wide range of services. Costello (1989b)
initially found a prevalence rate of 24.7% for one or more DSM-III disorders based on the parent-report CBC.
Detailed follow-up interviews with 300 parents and their children, using the NIMH Diagnostic Interview
Schedule for Children (DISC: Costello, Edelbrock, Kalas, Kessler, & Klaric, 1982), yielded a prevalence rate
for one or more DSM-III disorders of 22.0% + 3.4%.
It should be noted however, that the sample for the PCPS (Costello, 1989b) was drawn by soliciting the co-
operation of families containing an age eligible child visiting a primary care clinic during one calendar year.
Thus, it is not known how applicable the findings are to the children who did not visit their paediatrician at
least once during the year. Health records indicated that approximately 75% of children in the 7 to 11 year
age range visit a paediatric clinic at least once a year. This prompted Costello (1989b, p. 851) to declare that
"a random sample collected in a primary care setting is reasonably representative of the general population
and can provide an estimate of the rates and correlates of disorders among children". However, no
information was provided regarding whether those children attending the primary care clinic differed from
those that did not (Costello, 1989b).
19
Other studies published toward the end of the 1980s included the Puerto Rico Child Psychiatry
Epidemiologic Study (PRCPES: Bird et al., 1988) which was based on DSM-III diagnoses and a functional
impairment score greater than 61 on the Children's Global Assessment Scale (CGAS: Shaffer et al., 1983).
Bird et al. (1988) reported a six-month prevalence rate of 17.9% for 6 to 16 year-olds. Comparable results
were also reported from the New York Child Longitudinal Study (NYCLS: Velez et al., 1989), where 17.7% of
776 children and adolescents (aged 9-18 years), randomly chosen from households in New York State, were
found to meet the criteria for one or more disorders.
A more recent study was the Dunedin Multidisciplinary Health and Development Study (DMHDS: McGee et
al., 1990) which investigated the prevalence of DSM-III disorders from a general population in Dunedin, NZ.
The prevalence rate among 15 year-old children (n=943), as determined by an abbreviated version of the
DISC and parent completion of the Revised Behaviour Problem Checklist (RBPC: Quay & Peterson, 1987),
was 22%. The most prevalent disorders reported were overanxious disorder, nonaggressive CD, and simple
phobia (McGee et al., 1990).
It should be acknowledged that the prevalence rate of 22% may be under-reported due to the researchers
use of an abbreviated version of the DISC. Although the DISC interview provided full criteria for DSM-III
disorders, in some instances it provided less opportunity for reporting additional criterion symptoms. By the
authors own admission, "if anything, this could have the effect of underestimating the prevalence of particular
disorders" (McGee et al., 1990, p. 617). In addition, as previously mentioned, studies using interviews have
traditionally tended to produce lower estimates due to social desirability (McGee et al., 1990). Furthermore,
the prevalence rate reported represented the findings among 15 year-old children only. Taking into account
that the prevalence of child and adolescent disorder increases with age, a study that also included older
adolescents would have reported a higher prevalence result. Furthermore, McGee et al. (1990, p. 612)
declared that the sample was "socioeconomically advantaged to a certain degree when compared with the
remainder of NZ on an index of socioeconomic status". Given the greater reported prevalence of disorder
among lower socioeconomic groups, a sample representing the population as a whole may have produced a
higher estimate.
One of the few longitudinal studies which has examined the prevalence of child and adolescent disorder, and
the first to use DSM-III-R diagnoses, was the Christchurch Health and Development Survey (CHDS:
Fergusson et al., 1993) in NZ. The CHDS involved a birth cohort of 1265 children born in the Christchurch
urban region during mid-1977. These children were studied at birth, four months, and at annual intervals
through to the age of 15 years (Fergusson et al., 1993).
The objective of the study was to document the prevalence of 12 DSM-III-R diagnoses. Parent and child-
reports were obtained on children's levels of DSM-III-R symptomatology for five major groups of diagnoses:
AnxDs, mood disorders, conduct/oppositional disorders, ADHD, and substance abuse/dependence
(Fergusson et al., 1993).
Overall, approximately 25% of children met the criteria for at least one DSM-III-R diagnosis which is slightly
higher than that found in a number of studies reported earlier The reasons for this include: both child and
parent-reports were employed; the investigation of 12 disorders is likely to produce higher estimates (and
more accurate estimates) than studies based on as few as four (e.g., Offord et al., 1987); and according to
Greenberg (1997, p. 68) the "increase in prevalence results can also be attributed in part to the use of
different diagnostic systems (i.e., DSM-III versus DSM-III-R)".
It remains impossible to determine whether there has been an increase in the actual prevalence of child and
adolescent disorder, or merely an increase in the accuracy of identification due to the evolving DSM system
(Doll, 1996). There are very few child and adolescent studies employing the DSM-III-R, and, more
significantly, the DSM-IV diagnostic system, to form an opinion. Population studies have however, reported a
marked increase in the prevalence of disorder.
At its inception in 1980, the Epidemiologic Catchment Area Study (ECA: Robins & Regier, 1991) was the first
large-scale, multisite study to undertake a prevalence survey using DSM-III criteria (Greenberg, 1997). Data
on disorders were gathered from over 20,000 adults using the Diagnostic Interview Schedule (DIS: Robins,
Helzer, Croughan, & Ratcliff, 1981), a structured diagnostic interview for assessing DSM-III disorders
(Greenberg, 1997). Based on the results of the full ECA (Robins & Regier, 1991) research cohort, the
lifetime (symptoms experienced during the present and/or past) prevalence rate for DSM-III disorders was
judged to be 32%, with an annual (past year) prevalence rate of 20%, and a monthly (past month)
prevalence rate of 15.4%.
20
The National Comorbidity Survey (NCS: Kessler et al., 1994) was the second, large-scale prevalence study
undertaken in the USA, designed in part to remedy some of the methodological drawbacks of the earlier
ECA (Robins & Regier, 1991). The NCS (Kessler et al., 1994) study obtained its diagnostic interview data
from a nationally representative sample of 8098 individuals. Laypeople were utilised as interviewers, and a
modified version of the Composite International Diagnostic Interview (CIDI: World Health Organisation
[WHO], 1994a) was used to obtain DSM-III-R diagnoses. Participants ranged in age from 15 to 56 years, and
the response rate among those asked to participate was 82% (Greenberg, 1997). Based on the results from
the full NCS (Kessler et al., 1994) dataset, the lifetime prevalence rate for DSM-III-R disorders was judged at
48%, with an annual prevalence rate of 29% (Kessler et al., 1994). These prevalence rates are substantially
higher than those found in the ECA (Robins & Regier, 1991) study, and this difference was attributed by the
authors, in part, to the use of different diagnostic systems (i.e., DSM-III versus DSM-III-R).
Prevalence of individual disorders:

The literature reviewed thus far has provided evidence of the prevalence of child and adolescent disorder.
Although a number of studies have investigated the prevalence of each of the specific disorders (e.g.,
ADHD, OCD, TD) separately, as with child and adolescent disorder studies, huge variations occur as a result
of the different methodologies and diagnostic criteria employed. For example, the prevalence of generalised
anxiety disorder (GAD) has been reported from as low as 1.6% (Wittchen, Zhao, Kessler, & Eaves, 1994) to
as high as 21% (Kashani, Orvaschel, Rosenberg, & Reid, 1989).
In the interest of brevity, the range of prevalence findings for the most common child and adolescent
disorders are provided in Table 1. To be acceptable for inclusion in Table 1, the reported prevalence studies
must have comprised general population samples, both genders, and contain child and/or adolescent
participants. Specific disorders were chosen on the basis of being perceived to be the more common, as
determined by the literature, among the more prevalent major disorder categories. The more prevalent major
disorder categories according to recent research (e.g., Carlat, 1998; Doll, 1996; McGee et al., 1990) are the
AnxDs, ADDBDs, ComDs, DepDs, EDs, LDs, pervasive developmental disorders (PDDs), and tic disorders
(TicDs).
21
Table 1
Range of prevalence data for the most common disorders according to the literature
Disorder Category Lowest Highest

Specific Disorders %/Age/Author(s) %/Age/Author(s)
Anxiety Disorders
Generalised Anxiety Disorder 1.6/15-54/Wittchen et al., 1994 21.0/8-17/Kashani et al., 1989
Obsessive-Compulsive Disorder 1.0/14-18/Flament et al., 1994 7.1/21/Newman et al., 1996
Attention-Deficit and Disruptive Behaviour Disorders

Attention-Deficit/Hyperactivity Disorder 1.2/15/McGee et al., 1992 12.6/9-18/Velez et al., 1989
Conduct Disorder 2.0/11/McGee et al., 1992 11.7/9-18/Velez et al., 1989
Oppositional Defiant Disorder 1.3/11/McGee et al., 1992 18.6/13-18/Velez et al., 1989
Communication Disorders
Expressive Language Disorder 2.69/0-17/Dyrborg & Goldschmidt, 1996 15.2/1-6/Baltaxe & Simmons, 1988a
Mixed Receptive-Expressive Language Disorder 2.61/0-17/Dyrborg & Goldschmidt, 1996 9.6/1-6/Baltaxe & Simmons, 1988a
Phonological Disorder 0.5/17/APA, 1994 2-3/6-7/APA, 1994
Depressive Disorders
Dysthymic Disorder 1.4/11/McGee et al., 1992 6.4/8-11/Polaino-Lorente & Domenech, 1993
(Table 1 continued over page)
22
(Table 1 continued)
Disorder Category Lowest Highest

Specific Disorders %/Age/Author(s) %/Age/Author(s)
Eating Disorders
Anorexia Nervosa 0.3/13-18/Whitaker et al., 1990 0.40/15/Rastam, Gillberg, & Garton, 1989
Bulimia Nervosa 0.02/10-64/Hoek et al., 1995 0.63/15-65/Garfinkel et al., 1995
Learning Disorders
Disorder of Written Expression * *
Mathematics Disorder 1.3/9-10/Lewis, Hitch, & Walker, 1994 6.5/11/Gross-Tsur, Manor, & Shalev, 1996
Reading Disorder 2/6-17/Riccio & Hynd, 1995 8/7-10/Shaywitz, Shaywitz, Fletcher, & Escobar, 1990
Pervasive Developmental Disorders

Asperger's Disorder 0.36/7-16/Ehlers & Gillberg, 1993 .71/7-16/Ehlers & Gillberg, 1993
Autistic Disorder 0.08/2-4/Baron-Cohen et al., 1996 .12/4-13/Gillberg, Steffenburg, & Schaumann, 1991
Tic Disorders
Tic Disorder (Motor & Vocal) 3/10-14/Kurlan et al., 1994 10/6-12/Fallon, Jr. & Schwab-Stone, 1992
Tourette's Disorder 0.03/5-18/Caine et al., 1988 2.99/13-14/Mason et al., 1998
* No prevalence rates available as at time of completion
23
As is evident in Table 1, the prevalence rates for all disorders vary markedly.
Influence of Gender on disorder:

Another reason why prevalence results vary so much between studies, not withstanding the previously
mentioned methodological considerations, is that the gender of the participants has not been taken into
consideration. Traditionally, studies have indicated that males are more prone to disorder than females. So
much so, that the common perception is that boys are two to three times more likely as girls to have a
diagnosable condition across most of the disorder categories (Esser, Schmidt, & Woerner, 1990; Tongue,
1998). However, empirical studies have shown the difference to be substantially less. For example, Leslie
(1974), in a study of 13 to 14 year-olds in Blackburn, United Kingdom (UK), estimated that 21% of boys and
14% of girls in their sample had a moderate to severe disorder. Similar findings were reported from the main
study of the Western Australian Child Health Survey (WACHS: Garton, Zubrik, & Silburn, 1998), in which
2737 children between the ages of 4 and 16 years (from 1462 randomly selected households) completed the
CBCL (Achenbach, 1991; Achenbach & Edelbrock, 1983; 1987). Results of this study indicated the
prevalence of males with a disorder to be higher than females (20% versus 15.4%).
Although in the above studies prevalence rates for disorder were found to be greater in males than in
females, it may have been a function of the individual disorders investigated. For example, it has frequently
been reported that ADDBDs are more frequent in males than females (Lewinsohn et al., 1993; Nottelmann &
Jensen, 1995). This is consistent with the findings of Offord et al. (1987) who found that adolescent males
had a higher prevalence of CD (8.1% vs 2.7%) and hyperactivity (8.9% vs 3.3%) than females. Similar
results have been repeated across studies investigating LDs, in which ratios ranging from 3:1 to 15:1
(males:females) have been reported (Finucci & Childs, 1981; Vogel, 1990).
In comparison, there has also been a number of studies in which females have been depicted as having a
greater prevalence rate of disorder than males. For example, an early study by Krupinski et al. (1967)
reported the prevalence of disorder among 14 to 21 year-olds in Victoria, Australia to be 19% for boys and
22% for girls. More recently, in the CHDS (Fergusson et al., 1993), rates of disorder were reported to be
higher for girls (32.55%) than for boys (20.35%), with the difference being largely attributed to higher rates of
anxiety and mood disorders among girls. In line with this finding, Kashani et al. (1989) in a study of 7 to 17
year-olds found 28.6% of females reported GAD in comparison with 13.3% of boys. Similarly, in the DMHDS
(McGee et al., 1990), prevalence rates of disorder were reported as 25.9% for females and 18.2% for males.
Once again, the finding of an overall female predominance for disorder was attributed to this higher
prevalence of AnxDs and DepDs (McGee et al., 1990).
Therefore, it would seem that it is the types of disorders investigated that play a role in determining which of
the genders have higher prevalence rates of disorder. For example, males exhibit more LD (Finucci & Childs,
1981; Vogel, 1990) and ADDBD (Lewinsohn et al., 1993; Nottelmann & Jensen, 1995; Offord et al., 1987),
while females demonstrate a far greater prevalence of internalising disorders such as anxiety and
depression (Kandel & Davies, 1986; Kashani et al., 1987; McGee et al., 1990).
There is some conjecture about this, however, as there appears to be a downward movement in reported
prevalence from males to females with increased age. Therefore, the prevalence of one or more disorders
may be significantly related to both age and gender. For example, the DMHDS (McGee et al., 1990) found
the male-female ratio for diagnosis in 11 year-olds to be 1.3:1. Males exhibited more ADHD, CD,
oppositional defiant disorder (ODD), and depression, while girls more commonly exhibited AnxDs. Four
years later (at 15 years of age) the male-female ratio had shifted to 0.7:1, with higher rates for girls for all
disorders except ADHD (McGee et al., 1992). Similarly, ODD rates in the Kashani et al. (1987) sample of 14
to 16 year-old adolescents was also found to be higher for girls (8.0%) than boys (4%). This was also the
case with the OCHS (Offord et al., 1987) where prevalence in children aged 4 to 11 years was higher among
males than females (19.5% vs 13.5%), while the reverse was true among adolescents aged 12 to 16 years
(18.8% for males and 21.8% for females).
Although it is unknown why females tend to surpass males in terms of disorder prevalence, one particular
view that has been well documented (e.g., Angold, 1988) is that rates of anxiety and mood disorders
increase after puberty (Fergusson et al., 1993). In accord, rates for dysthymic disorder (DD) were found in a
New York sample (Cohen et al., 1993) to be more similar for boys and girls in childhood than in adolescence
where they were generally higher for girls than for boys. Moreover, by late adolescence, rates again were
similar for boys and girls, suggesting that affective disorders among girls may peak during mid-adolescence.
Similarly, Lewinsohn et al. (1993, p. 143) declared that "the gap that already existed at age 14 between
females and males did not widen". Thus, to find the age at which female adolescents begin to surpass male
adolescents will require studies of children and adolescents which involve as full an age range of the school
population as possible.
24
Influence of Age on disorder:
A further reason why prevalence results vary so much between studies is that the age of the participants has
not been taken into consideration. The limited data available suggest that there is a slight rise in the
prevalence rate of disorder between late childhood and early adolescence (Rutter et al., 1976). For example,
the 12 month DSM-III prevalence rate in the DMHDS (McGee et al., 1990) among 11 year-old children
(n=792) was 17.6%. When the prevalence rate for the majority of these same 11 year-olds was adjusted for
comparability with the data for follow-up four years later, the overall prevalence rate rose to 19.6% at age 15
years (McGee et al., 1992).
Similarly, the OCHS (Offord et al., 1987) reported that the rates for the older age group (12-16 years) were
significantly higher than the rates for the younger age group (4-11 years). In a subsequent follow-up of the
OCHS sample at age 18 years, Feehan, McGee, and Williams (1993) reported a dramatically increased
prevalence rate of 36.3%. However, it is difficult to compare these two studies, as the prevalence rates were
derived from different informants and based on different diagnostic criteria.
To examine developmental trends of child and adolescent disorder, the PRCPES (Bird et al., 1988)
investigators also compared the rates of disorders across three age groups: 4-5 year-olds, 6-11 year-olds,
and 12-16 year-olds. Results indicated that the prevalence rate of ADHD was lowest in the youngest group
(4-5 year-olds), compared to the two older groups. Also the rate of depression was higher in each
successively older group, while separation anxiety disorder (SAD) was found at a higher rate in the 6 to 11
year-old group than in both the younger and older groups. In accord, Nottelmann and Jensen (1995)
reported that ADHD, CD, and ODD rates tend to peak in late childhood and early adolescence, and the rate
of SAD tends to be highest in late childhood and quite low in adolescence. This finding led Nottelmann and
Jensen (1995, p. 124) to declare that "the general pattern across studies suggests that SAD is transient and
most likely to be confined to late childhood or early adolescence".
In a review of the main study comprising the WACHS (Garton et al., 1998, p. 35) the researchers reported
that "mental health morbidity" was identified in 17.7% of the sample, with 12 to 16 year-olds displaying a
higher morbidity than 4 to 11 year-olds (21% versus 16%). It should be noted, however, that whilst the
findings of this study are commensurate with the majority of the literature, the WACHS (Garton et al., 1998)
utilised the most recent CBCL which does not provide the "real" specific categorisation of mental health
problems. Rather, this instrument "probes behaviours indicative of mental health morbidity" (Garton et al.,
1998, p. 35) and identifies categories of delinquent behaviour, aggressive behaviour, withdrawn,
anxious/depressed, somatic complaints, social problems, thought problems, and attention problems.
One of the few studies not to have produced elevated prevalence rates in the older age groups is that by
Esser et al. (1990). In this study, Esser et al. (1990) screened a birth cohort of 1444 children aged eight
years in Mannheim, Germany, using a parent and teacher completed instrument. Data provided by the
parents of 216 children, randomly selected to receive a structured interview, revealed a six-month disorder
prevalence rate of 16.2% at age 8 years. At age 13 years, prevalence rates were remarkably similar: 16.2%
without adolescent interview data, and 17.8% with adolescent interview data. The effect of age on
prevalence and incidence of disorder was not significant. Thus, the hypothesis of an increase in the
prevalence of disorder between 14 and 18 years of age was not supported by the findings of Esser et al.
(1990).
Influence of Socioeconomic Status on disorder:

A well-documented correlate is the greater prevalence of disorder among lower socioeconomic groups
(Bruce et al., 1991; Holzer et al., 1986; Tongue, 1998; Weich et al., 1997; Williams et al., 1992). Almost all of
the research supporting this perspective however, is based solely on adult studies. It would appear to be a
presumption, therefore, that SES exerts the same influence on child and adolescent disorder.
In a cohort study of 261 consecutive primary care attendees (aged 16-65 years) in South London, UK, the
estimated prevalence of disorder was reported to be 45.6%. The types of risk factors associated with the
incidence and maintenance of disorder in the study population including SES variables (especially low
household income and not having a partner) were strongly associated with a worse outcome among
prevalent cases (Weich et al., 1997).
Although this study reported findings commensurate with previous SES studies, the data must be interpreted
with caution due to the sample comprising "primary care attenders". A sample of this type may have affected
the prevalence findings (45.6%) as well as the influence of SES factors. Furthermore, since the majority of
disorders are known to increase in prevalence with age, a sample consisting of adults would not be
indicative of rates within a child and adolescent sample.
25
In a recent large-scale study, Bruce et al. (1991) assessed the effect of poverty (an indication of low SES) on
the presence of a disorder using solely the New Haven, Connecticut, ECA data. Poverty was defined using
USA federal poverty guidelines, and the presence of a disorder was assessed by the DIS. Interviews were
conducted with a sample of 3497 adults aged 18 years and over. Respondents meeting criteria for poverty
were found to have almost a two-fold increased risk (controlling for demographic factors) for an episode of at
least one DSM-III disorder (12.8% versus 7.1%). Rates of specific disorders were comparably higher for
respondents meeting poverty criteria compared with those not in poverty, although these differences were
not always statistically significant. Overall, the effect of poverty did not differ by gender, age, race, or history
of a disorder episode.
Researchers have only recently been able to specify the cross-sectional relationships between SES and
specific disorders. In the past, community-based studies have generally measured symptoms within the
domain of a specific disorder (in particular depression). Considerable variation exists in the variables and
clinical manifestations of the different disorders defined by the DSM-III, suggesting that the relationship
between poverty and any single measure should not be generalised across a range of disorders. Moreover,
because the prevalence of the specific disorders vary widely and there is a great deal of comorbidity among
disorders, findings based on aggregate measures may well be weighted by the effects of the more prevalent
disorders (Bruce et al., 1991).
Factors contributing to the nonidentification of disorder:

The findings pertaining to the prevalence rate of child and adolescent disorder in the community have varied
markedly between studies. Despite these prevalence data having traditionally been criticised for being too
high, the prevalence rates being reported still appear to be somewhat conservative (Costello et al., 1988).
The reported rates differ from true prevalence rates in that they reflect only those individuals who have been
identified and subsequently referred for diagnosis and treatment.
This latter point, of why some children and adolescents with a disorder are identified, whilst others are not,
requires further investigation.
Factors contributing to the nonidentification of disorders include:
(i) Gender and Age factors;

(ii) children not being involved in the rating of their own symptomology;
(iii) the nature of the disorders (many internalising disorders are not identified);
(iv) comorbidity of disorders (Costello & Janiszewski, 1990); and
(v) the absence of an appropriate screening instrument;
As a result of the abovementioned factors, it is recognised that the majority of children and adolescents with
a disorder are not identified (Anderson et al., 1987; Costello, 1989a; Costello et al., 1988; Offord et al.,
1987). Moreover, in studies of the provision of services to children and adolescents with a disorder, the over-
riding finding is that services only reach a minority of those with a disorder (Fergusson et al., 1993; Offord et
al., 1987). For example, although the OCHS (Offord et al., 1987) found significant psychopathology in 18.1%
of 3294 children aged 4 to 16 years, only 6.5% (16.1%) of children with a disorder had received any services
from mental health or social service providers during the past six months. In the CHDS (Fergusson et al.,
1993) only 21% of children with a disorder were in contact with any service for their problems, while in the
Isle of Wight study (Rutter et al., 1976), 90% of the children with a disorder had not been expertly diagnosed
or assessed, let alone treated. Similarly, in New York, USA, Lagner et al. (1974) noted that less than 50% of
the seriously impaired children were referred, and only one in five received treatment for six months or
longer.
Acknowledging the possibilities that a number of children meeting criteria may have received false-positive
diagnoses, and that not all children meeting criteria would have been willing to seek assistance or treatment,
these findings bear out the general contentions of a number of authors (e.g., McGee et al., 1990; Whitaker et
al., 1990) that child and adolescent disorders tend to be under-recognised and undertreated (Fergusson et
al., 1993).
One point of controversy pertaining to nonidentification however, is that experiencing emotional symptoms or
even receiving a disorder diagnosis does not constitute the need for treatment. According to Fones, Kua, Ng,
and Ko (1998, p. 251), "community prevalence identification tends toward diagnosis of the milder, borderline
conditions, for which there is no clear boundary with normality". Tongue (1998) believed childhood disorder
problems that require treatment affect about 5-10% of young people at some time. Similarly, Kashani et al.
(1987) interviewed children and parents in a small community sample of 14 to 16 year-old adolescents using
the Diagnostic Interview for Children and Adolescents (DICA; Herjanic & Campbell, 1977; Herjanic & Reich,
26
1982) and reported a prevalence rate of 41.3% for diagnoses meeting DSM-III criteria. However, a lower rate
of 18.7% was identified with the imposition of additional criteria for impaired functioning and need for
treatment.
Despite these high prevalence rates of child and adolescent disorder requiring treatment, Knitzer (1993)
estimated that only 5% of school-aged children and adolescents were receiving mental health services from
medical centres, clinics, private practitioners, or community mental health agencies. This is relatively small
when taking into account that the most recent studies indicate at least 20% of the child and adolescent
population present with a disorder.
Contribution of Gender to the nonidentification of disorder:

The general contention is that males have a higher chance than females of their disorders being identified
and receiving treatment (Costello & Janiszewski, 1990). For example, the OCHS (Offord et al., 1987) found
that the ratio of boys to girls with one or more disorders was 1.13 to 1, whereas the ratio of boys to girls
receiving treatment was 1.53 to 1. This effectively means that boys were almost 50% more likely than girls to
have been in contact with a mental health or social service agency. This was the case for both children and
adolescents, and applied whether the child had a disorder or not (Costello & Janiszewski, 1990).
It maybe, however, that this is a direct result of the types of disorders involved. For instance, it has long been
believed that significantly more males than females have ADDBD and LD (Vogel, 1990). This results in more
frequent referrals and provision of special education services for boys with LD (Vogel, 1990). Based on the
literature reviewed, Vogel (1990, p. 50) declared that "in order for females to be identified for referral and to
be diagnosed as LD, they have to (a) be significantly lower in intelligence than the referred males, (b) be
more severely impaired, or (c) have a larger discrepancy between aptitude and achievement".
There is also evidence that teachers have a differential attitude in that they favour referring males even when
females have identical problems (Vogel, 1990). For these reasons, females with the same degree of
discrepancy, type, and severity of LD do not come to the attention of their parents and teachers as frequently
as their male siblings and classmates (Vogel, 1990).
Contribution of Age to the nonidentification of disorder:

Many problems pertaining to the diagnosis of disorder has been attributed to the age of the children and
adolescents, in combination with the methodology employed. Young children, for example, have been found
to be reliable reporters in many symptom areas thereby indicating the appropriateness of using direct
questions about past experiences, emotional states, and behaviours from an early age (Edelbrock et al.,
1985). However, with young children, particular care is needed to avoid leading questions (Angold, 1996).
According to Edelbrock et al. (1985) highly structured interviews with children below 10 years of age should
be interpreted cautiously so as to not produce excessive false-positives or failure to identify true cases.
Similarly, it is well documented that young children respond poorly when asked to perform tasks that are
beyond their cognitive capacities, or asked questions using words they do not understand (Edelbrock et al.,
1985). Therefore, interviews, such as the widely utilised DISC, need to incorporate questions that are easily
understood by young children, but which do not appear condescending to older adolescents (Edelbrock et
al., 1985). Furthermore, to reduce task complexity, questions need to be limited to short, easily understood
words, with sentence length rarely exceeding 10 words (Edelbrock et al., 1985). Interview schedules not
abiding by these guidelines are more likely to exhibit low reliability when involving young children.
The first systematic examination of the reliability of the DISC in relation to age was conducted by Edelbrock
et al. (1985). The DISC was administered to 242 children and adolescents (aged 6-18 years) who had been
referred for inpatient or outpatient mental health services. The sample was divided into three age groups: 6-
9, 10-13, and 14-18 years of age. Results revealed that the reliability of the child's self-report increased with
age for the 6 through 9 year-olds, with many symptom areas showing only marginal or poor reliability. This
led the researchers to advise caution in using highly structured interviews with children aged 10 years or
younger.
The identification of disorders at as young an age as possible is extremely important for treatment options
because strong evidence exists that a large number of adolescent disorders have their origins in childhood.
For example, Rutter et al. (1976) found approximately 40% of disorders seen in adolescence had persisted
since childhood and the rest had newly developed during early adolescence. Similarly, up to 50% of adult
27
cases of OCD have been reported to have begun by the age of 15 years (Rapoport, 1986) and patients with
ED typically report that their symptoms began during adolescence (Garfinkel & Garner, 1982).
These data typify the subjectivity of the age of onset of these disorders, thereby highlighting the need for
future prevalence surveys to cover a wide age range of children in order to extend our knowledge of the
distribution, correlates, and typical age of onset of child and adolescent disorders (Offord, 1985).
Contribution of Informant to the nonidentification of disorder:

Another issue influencing the nonidentification of child and adolescent disorder is that of the use of several
different informants: child/adolescent, parent, teacher, and clinician. Parents have been the cornerstone of
child and adolescent disorder assessment because they can provide more information on their child's
development, behaviour, and abilities than any other informant, as well as being responsible for initiating
most child mental health referrals (Angold, 1996; Edelbrock et al., 1985; Rohrbeck et al., 1991). However,
adult ratings have not escaped criticism (Hughes, 1988). For instance, parent-reports can be biased due to
their subjectivity (Achenbach & Edelbrock, 1978; Barkley, 1981; Breen & Altepeter, 1990). Teacher-reports,
on the other hand, may reflect an idiosyncratic teacher-pupil relationship or a child's behaviour in only one
structured situation (e.g., mathematics class) instead of their behaviour across all situations (Beitchman, &
Corradini, 1988; Karoly, 1981; Rohrbeck et al., 1991). Despite these unfavourable findings, adult ratings
have traditionally been preferred over children's ratings of their own behaviour due to the child's information
being viewed as suspect, on the grounds of mnemonic deficiency or unreliability (Edelbrock et al., 1985).
The reliability of children's self-report is a key issue, for if children misunderstand questions or fail to express
themselves accurately, they may give erratic and unreliable responses. Consequently, such data will
contribute little to valid clinical appraisal or accurate diagnosis (Edelbrock et al., 1985).
One study that investigated the reliability of child and adolescent self-report was that conducted by
Edelbrock et al. (1985). Two-hundred and forty-two children and adolescents were assessed twice, using the
DISC, at a median interval of nine days. The parents of these children also completed the DISC twice on
their child's behalf. Intraclass correlations between symptom scores derived from the interviews indicated
that parents were generally more reliable than children in reporting child symptoms. However, test-retest
reliabilities showed an opposite age pattern for the parent and child with the reliability of child's self-report
increasing with age: lower for children aged 6-9 years than those aged 10-13 years and 14-18 years.
Conversely, the reliability of the parent's report decreased with the age of the child, being slightly higher for
children aged 6-9 than those aged 10-13, and 14-18 years.
The improved reliability of child self-report with increasing age was interpreted by Edelbrock et al. (1985) in
terms of improving cognitive, memory, and language skills. The inverse relationship between the child's age
and the reliability of the parent-reports was attributed in part to decreasing exposure to children's behaviour
and shifting behavioural norms (Edelbrock, et al., 1985). From middle childhood on, most children spend an
increasing amount of time outside the home, and their social activities shift to other arenas such as school
and organised sports, clubs, and activities. Consequently, parents have fewer opportunities to observe older
children's social, emotional, and behavioural functioning. Behavioural norms also become more fluid in
adolescence, and it may become more difficult for parents to judge certain behaviours (e.g., excess activity,
anxiety, moodiness) as pathognomonic (Edelbrock, et al., 1985).
When proposing at what age a child's self-report is reliable enough to contribute to clinical assessment,
Edelbrock et al. (1985) stated that there is no absolute reliability standard. However, if a test-retest reliability
of .70 is used as a criterion, children aged 10 years and older are reliable reporters. This suggests that while
younger children (<10 years) should still act as informants, the information provided should be interpreted
cautiously (Edelbrock et al., 1985).
With the advent of empirical evidence pertaining to acceptable reliability of children's self-report there has
been a move toward viewing children as valuable informants regarding their own behaviour, perceptions,
experiences, and feelings (Mash & Terdal, 1988). Furthermore, self-report can contribute greatly to an
understanding of child and adolescent disorders, since it has been shown that the experience of children is
not identical to the attributions of their symptoms by parents, teachers, and clinicians (Achenbach &
Edelbrock, 1978; Herjanic & Reich, 1982). This is particularly so for signs and symptoms that do not only
describe observable behavioural manifestations, but are more closely linked to internal emotional states,
such as anxiety and depression (Weinstein et al., 1990). For example, in the PCPS (Costello, 1989b) a total
of 53 out of 300 children (11.8%) received one or more diagnoses based on the interview with the parent,
and 61 children (13.8%) received one or more diagnoses based on the interview with the child.
28
Use of both child and parent sources yielded a weighted prevalence of 22.0%, which suggests that reliance
on only parental information would have identified approximately half of the children meeting criteria for
DSM-III disorders (Costello, 1989b). More specifically, on the basis of parent-reports alone, more than half of
those children with emotional problems and one-quarter of the children with behavioural problems, would
have gone unidentified (Costello, 1989b). A similar discrepancy between child-report and parent-report is
found in the CHDS (Fergusson et al., 1993). On the basis of self-report, 22.1% of the sample met criteria for
at least one disorder in comparison with only 13.0% on the basis of parent-report only. This difference was
found to be highly statistically significant (p<.001). There was also a clear tendency for maternal reports of
internalising symptomatology (e.g., anxiety, mood disorders) to be substantially lower (2-3 times) than the
reported rates based on child-report (Fergusson et al., 1993). The likelihood that children came to the
attention of their parents for problems varied according to the child's symptomatology: 9% of children with
anxiety or mood disorders only came to attention; 26% of children with conduct problems, attention-deficit, or
substance abuse, only came to attention; whereas 35% of children with both mood/anxiety disorders and
disruptive behaviour/substance use disorders came to attention (Fergusson et al., 1993).
In addition, the investigators in the PCPS (Costello, 1989b) compared the rate of their disorder diagnosis
(22%) with that identified by paediatricians (5.7%), or referred by the paediatricians (3.8%). Only 1.9% had
received any mental health services during the previous year despite the children with a disorder being
markedly more impaired in their daily functioning than the children without diagnosis (Costello, 1989b).
Family physicians frequently diagnose and treat disorders, particularly in patients enrolled in managed care
plans (Carlat, 1998). According to Schulberg and Burns (1988) 25-30% of patients presenting to primary
care physicians have at least one disorder. Although estimates of missed diagnosis are probably inflated and
overemphasised (Coyne, Schwenk, & Fechner-Bates, 1995), studies (e.g., Schulberg & Burns, 1988)
indicate that 30-80% of these cases are undetected by primary care physicians.
One study that brings to light a number of issues regarding the effectiveness of parent, teacher, and clinical
informants is that by Costello and Janiszewski (1990). In this study, children aged 7 through 11 years from
the same large industrial city in north-eastern USA, were screened for behavioural problems using the CBC.
One group was attending a primary care paediatric clinic and receiving no psychiatric treatment, while the
other group attended a tertiary care child psychiatric clinic. Both groups were significantly disturbed
according to their mothers. Eighty-nine treated and 126 nontreated children (who had not received treatment
in the previous year), all of whom scored in the clinical range (above the 90th percentile) on the CBC, were
compared on measures of psychopathology, environmental factors, and adaptive functioning. All of the
children were subsequently assessed for disorders using the DISC.
Results revealed no difference between the groups in the proportions receiving a disorder diagnosis, or in
the proportions with more than one disorder. The nontreated disturbed children were as likely as the treated
ones to have ADHD, an AnxD, and ODD, and to be failing at school. Costello and Janiszewski (1990, p. 523)
concluded that "the treated children had more cases of CD and DepD, and were more likely to be male (76%
of males vs 53% of females)".
In the same study, teachers reported twice as many behavioural problems in treated as untreated children,
suggesting that adults' discomfort with children's behaviour may have been a more potent precipitator of
referral than the children's failure to perform well at school (Costello & Janiszewski, 1990). The findings
suggest that many nontreated children may be no less impaired than those who receive treatment, and that
factors other than severity of psychopathology may dictate which disturbed children receive mental health
services (Costello & Janiszewski, 1990).
It must be noted however, that data were not collected primarily to address the question of which disturbed
children received treatment, but as part of two separate studies of rates and risk factors for a disorder. Thus,
several questions of interest to the present research were not asked. In particular, parents were not asked
directly why they had, or had not, sought treatment for the child. Afterall, it was stated by Costello and
Janiszewski (1990, p. 526) that "all the children in the two groups described here were judged by their
parents to have a significant level of emotional and behavioural problems". Reasons why the parents had not
sought professional help may include factors such as financial constraints, unwillingness of parents who do
perceive a problem to make use of these services, or perceived inaccessibility or unavailability of these
specialised resources (Offord et al., 1987)
Another concern is whether characteristics of the two service settings used in the study limited its
generalisability. For example, if the paediatricians had been particularly involved in mental health care, then
one would expect few of even the more disturbed children in their care to be referred for specialist treatment.
29
This might bias the results by swelling the nontreated group with children who, in other settings, would have
been treated, thus reducing the difference between the two groups (Costello & Janiszewski, 1990).
A disquieting implication of these analyses is the suggestion that children are more likely to receive
treatment if their behaviour upsets or annoys adults, particularly teachers, than if their disorder symptoms are
associated with failure at school and poor functioning at home, although the latter would seem to be the
more serious risk to children's futures (Costello & Janiszewski, 1990).
These results suggest that there exists among children and adolescents a large pool of untreated disorders,
and that these are largely unrecognised even by parents and physicians who see the children regularly. This
raises the question as to where the emphasis in terms of source of information should lie (McGee et al.,
1990). Reich and Earls (1987), for example, have suggested that a child's self-report, particularly in the case
of older children, may provide the best source of data for diagnosis, and that other sources of information
can be regarded as confirming or elaborating the child-report.
Contribution of Comorbidity to the nonidentification of disorder:

A further factor contributing to the nonidentification of disorder in children and adolescents is the masking
effect of comorbidity. At its simplest, comorbidity is the occurrence at one point in time of two or more
disorders (Clarkin & Kendall, 1992). On the basis of prevalence studies and the results from specific
populations, comorbidity among disorders can be considered extensive. Unfortunatlely, Prizant et al. (1990,
p. 186) stated that "current experience in our clinical setting and that reported in other settings for children
with emotional and behavioural disorders indicate that many children and adolescents with more subtle
forms of disorders often are not identified".
Researchers have established an empirical base substantiating the relationship between ComD and other
disorders (Baker & Cantwell, 1982a; 1982b; 1987a; 1987b; Beitchman, Nair, Clegg, Ferguson, & Patel,
1986; Cantwell, Baker, & Mattison, 1979; 1981; Gualtieri, Koriath, Van Bourgondien, & Saleeby, 1983).
However, the ComD is frequently the more covert disorder and thereby is often not identified. In line with this
are the findings of Gualtieri et al. (1983) who surveyed 40 consecutive admissions to a child psychiatric
inpatient facility. After in depth speech, language, and intelligence testing, it was found that 20 of the 40
admissions had previously unidentified moderate to severe ComD. Similarly, Cantwell (1987) reported that
approximately 50% of the children and adolescents admitted to the inpatient units of the Neuropsychiatric
Institute at the University of California, Los Angeles campus (UCLA), had a ComD, and of these, 40% had
not been diagnosed as having a ComD prior to admission for their emotional and/or behavioural disorders.
Therefore, children with significant behavioural disorders who also experience ComD from early in the school
years are often not identified as having ComD. They may be placed in classes for the behaviourally
disordered or emotionally disturbed, and because symptomatology of emotional and behavioural disorders
are most often the primary concern, more subtle communication problems that may be involved directly in
the development or perpetuation of the behavioural and/or emotional disturbance may be overlooked
(Prizant et al., 1990). Similarly, Burd et al. (1992) found that less than 25% of children with TD had their LDs
diagnosed in a school setting. The tics and other symptoms of TD, coupled with poor academic
achievement, were often attributed to disruptive behaviour (Burd et al., 1988).
Comorbidity was an important aspect of the study conducted by Costello and Janiszewski (1990). Every
child but one in the treated group, and 89% of those in the nontreated group, had at least one DSM-III
diagnosis following detailed interviews with the parent and child. Multiple diagnoses were made in the case
of 82% of the treated group despite only being diagnosed and treated for one disorder (Costello &
Janiszewski, 1990). However, among the nontreated children, 63% had more than one diagnosis (Costello &
Janiszewski, 1990).
In a study by Weinstein et al. (1990) a sample of 160 consecutively admitted inpatients on the child and
adolescent service of a large teaching hospital was interviewed using the DISC and the YSR. The patients in
this study were severely disturbed children and adolescents ranging in age from 11 to 16 years, with a mean
age of 14 years. Forty-six percent of the participants were male and 54% were female (Weinstein et al.,
1990). The number of DISC diagnoses ranged from 0-12, with a mean of 2.90 disorders and a standard
deviation (SD) of 2.33, despite most of the patients being treated for only one disorder. It is possible
therefore, that comorbidity may be more prevalent in inpatients than outpatients, however, the presence of
unidentified, and hence untreated disorders, in a clinic sample is still of concern.
30
Thus, ongoing identification is essential to provide appropriate services for children and adolescents with
disorders that are masked by a more overt comorbid disorder or that simply go undetected during the school
years.
Contribution of instrumentation to the nonidentification of disorder:

Structured Interviews:
One of the most commonly used methods for the identification of disorders is the structured interview. The
purpose of a structured interview is to collect information that will assist in the task of making a diagnosis and
formulating and implementing a treatment plan (Angold, 1996). This is achieved through an outline of target
behaviours, symptoms, and events to be covered, and some rules for asking questions and recording
responses from which the interviewer must not deviate (Edelbrock et al., 1985). The interviewer is required
only to know the rules governing when questions should be asked, and is then expected to follow the
interview schedule verbatim (Angold, 1996). Such an interview requires relatively little training to produce
proficient interviewers, and so nonclinician interviewers can be used. One knows exactly what has been
asked of each child, and can be sure that the questioning has been consistent from one participant to the
next. Several structured diagnostic interview schedules for children and adolescents have been developed,
including the DICA, the Child Assessment Schedule (CAS: Hodges, McKnew, Cytryn, Stern, & Kline, 1982),
the Interview Schedule for Children (ISC; Kovacs, 1983), and the most widely used DISC. Given the
popularity of the DISC it will now be covered in more detail.
Diagnostic Interview Schedule for Children:

The DISC is a highly structured diagnostic interview used in studies that are designed to cover a broad range
of symptoms and behaviours in children and adolescents aged 6 to 17 years. The NIMH commissioned the
construction of the DISC because of growing concern about administrative unawareness of the amount of
disorders seen in paediatric care settings (Costello et al., 1988). Therefore, information provided by the DISC
is used for making diagnoses of the more prevalent child and adolescent disorders according to criteria
specified in the DSM (Edelbrock et al., 1985; Fisher et al., 1993).
Since the construction of the initial DISC-I in 1981, the DISC has undergone a number of revisions and has
been subjected to a variety of methodological assessments including community, clinical, or combined
samples (Fisher et al., 1993). The current Diagnostic Interview Schedule for Children (DISC-IV: NIMH, 1997)
covers over 30 of the most common child and adolescent disorders that are not dependent on specialised
observation and/or test procedures. The interview covers diagnostic criteria as specified in the DSM-IV,
DSM-III-R, and the Tenth Revision of the International Statistical Classification of Diseases and Related
Health Problems (ICD-10: WHO, 1992).
There are parallel child and parent versions of the instrument. The Diagnostic Interview Schedule for
Children, Youth-report (DISC-Y: NIMH, 1997) is designed for direct administration to children and
adolescents aged 6 to 17 years, and the Diagnostic Interview Schedule for Children, Parent-report (DISC-P:
NIMH, 1997) is for the parents of children aged 6 to 17 years. A partial teacher version, limited to those
disorders that have symptoms that might be expected to be observable in a school setting, is currently in
preparation. The DISC-Y contains 2930 questions (the DISC-P contains slightly more), and of these, 358 are
stem questions, which are, by design, overly sensitive broad questions inquiring about the presence of
behaviours and are asked of every respondent. There are also 1341 contingent questions, which are only
asked if a stem question is answered positively, to determine whether the elicited behaviour meets a
diagnostic criterion; such questions inquire about duration, intensity, frequency, impairment, or other
modifiers used in DSM criteria. The contingent questions also effectively serve to "weed out" false-positive
responses (Fisher et al., 1993). There are also 732 questions pertaining to age of onset, impairment, and
treatment, and these are only asked if a clinically significant number of diagnostic criteria are endorsed
(about half of those required for a diagnosis). Additionally, the whole life module contains a total of 499
questions (NIMH, 1997).
Administration of the whole DISC-IV averages about 70 minutes per informant (youth or parent) in a
community population, and about 90 minutes to two hours for individuals who are receiving services (NIMH,
1997).
Checklists:
Many countries recognise that the various International Statistical Classification of Diseases and Related
Health Problems (ICD I-10: WHO, 1900-1992) and the DSMs have become the accepted checklists of
individual disorders (Kaslow, 1993). Therefore, it is not surprising that a large number of checklists have
been constructed using their criteria as guidelines.
31
International Statistical Classification of Diseases and Related Health Problems-Revision 10:
After a decade of development and testing, the WHO recently produced and published a revised
classification of mental and behavioural disorders termed the International Statistical Classification of
Diseases and Related Health Problems-Revision 10 (ICD-10: WHO, 1992). The ICD-10 is a system of
categories to which disease and health-related classifications are assigned according to established criteria
(Gersenovic, 1995). The purpose of the ICD-10 according to Gersenovic (1995, p.172) "is to permit the
systematic analysis, interpretation, and comparison of mortality and morbidity data collected in different
countries or areas and at different times".
Many checklists have been adapted from the ICD-10, in the same fashion as the DSM diagnostic system.
The main ICD-10 checklists are the CIDI; the Schedules for Clinical Assessment in Neuropsychiatry (SCAN;
WHO, 1994b), and the International Personality Disorder Examination (IPDE; WHO, 1992). These checklists
are a set of semistructured instruments designed for clinician assessment of mental and behavioural
disorders according to ICD-10 criteria (Janca & Hiller, 1996).
Diagnostic and Statistical Manual of Mental Disorders:

The most widely used diagnostic manual of child and adolescent disorders is the DSM-IV. The DSM-IV is so
widespread that it is used by virtually every mental health professional in the USA to guide diagnosis and to
justify third party reimbursement for treatment (Hinkle, 1994; Kaslow, 1993; Wakefield, 1992).
Each DSM-IV contains specific diagnostic criteria for 15 categories of disorders. The essential features and
clinical information associated with each disorder, as well as differential diagnosis considerations, are
provided. Information concerning diagnostic and associated features, culture, age, and gender
characteristics, prevalence, incidence, course, and familial pattern for each disorder are also included. Many
diagnoses require symptoms severity ratings (mild, moderate, or severe) and information about the current
state of the problem (e.g., partial and full remission) (Hinkle, 1994).
Adolescent Symptom Inventory-4:

One of the most comprehensive checklists comprising DSM-IV criteria is the Adolescent Symptom Inventory-
4 (ASI-4: Gadow & Sprafkin, 1997). The ASI-4 emerged out of a need to facilitate the gathering of
information between caregivers involved in young person's development in community and clinical settings
(Gadow & Sprafkin, 1997). The ASI-4 is a six-page checklist (120 items) for the behavioural, affective, and
cognitive symptoms of 24 adolescent disorders. These 24 disorders are described by the authors as "the
most common child and adolescent psychiatric disorders and the problem areas specified in the Individuals
with Disabilities Education Act" (Gadow & Sprafkin, 1997, p. 11).
The ASI-4 can be completed by parents, teachers, and other care providers who are familiar with an
individuals behavioural and emotional problems (Gadow & Sprafkin, 1997). Participants respond, for all of
the disorders except bipolar disorder (BD) and DD, on a four-point ordered scale anchored with the words
"Never" and "Always". The response options for the items pertaining to BD and DD are Yes/No.
Child Behaviour Checklist:

One commonly used checklist that is not modelled on either the DSM or ICD is the CBCL. The CBCL, which
consists of items assessing behaviour problems and social competence, has extensive normative data for
ages 2 to 16 years, and has acceptable reliability (Zaparniuk & Taylor, 1997). There are youth, parent, and
teacher versions, which are similar in format.
The Youth Self-Report (YSR: Achenbach, 1991) version of the CBCL is a symptom checklist designed to
establish an empirically based classification system of child psychopathology. Through the use of this form,
children and adolescents rate themselves on 20 items describing social competency (e.g., hobbies, sports,
peer relations) and 102 behavioural problems of clinical relevance (e.g., physical aggression, poor appetite,
sleep disturbance, fire setting) (Weinstein et al., 1990). The YSR form parallels the parent-report, with most
of the items of the CBCL appearing on the YSR, although seven of the items have been rephrased on the
YSR so as to be more readily understood by the child. Sixteen items appearing on the CBCL were omitted
from the YSR because of their inappropriateness for the self-report format, and the likelihood that they would
not be accurately reported by children (Weinstein et al., 1990).
Each of the three versions of the CBCL (youth, parent, and teacher) presents the participant with a list of
behavioural problems which are each rated according to whether a given behaviour is "not true" (scored 0),
"sometimes or somewhat true" (1), or "very true or often true" (2) of the individual (Zaparniuk & Taylor,
1997). Factor analysis was used to derive the CBCL subscales, some of which assess internalising problems
(e.g., somatic complaints, obsessive-compulsive symptoms) whereas other subscales assess externalising
problems (hyperactivity, aggression, and delinquency) (Zaparniuk & Taylor, 1997).
32
Strengths and limitations of interviews and checklists:
Interviews:
There is now a substantial body of literature on the psychometric properties of structured diagnostic
interviews with children and adolescents, which outlines the strengths and limitations of various approaches
to such interviews (see Angold, 1989; and Edelbrock & Costello, 1988, for reviews).
In the first place, it should be noted that structured interviews were originally developed because researchers
were aware that clinicians unaided by such instruments tended to operate in an idiosyncratic fashion, and
adopted inefficient decision rules in coming to a diagnosis (Angold, 1996). Using a structured format, one
knows exactly what has been asked of each child, and ensures that the questioning has been consistent
from one person to the next. Another advantage of these types of interview is that they can sample
information from multiple sources, including parents, teachers, and the child (Zaparniuk & Taylor, 1997).
Furthermore, such an interview requires relatively little training to produce proficient interviewers, and so
nonclinician interviewers can be used (Angold, 1996).
Of the available structured diagnostic interviews for children, the DISC has had the most extensive history of
development, including four field trials using community, clinical, and combined samples. Investigators have
used the DISC across a range of research settings, examined its sensitivity with rare conditions, and
evaluated its usefulness with young children (Fisher et al., 1993; Shaffer et al., 1993). As a whole, the DISC
has proven to be an acceptable, brief, inexpensive, and convenient instrument for ascertaining a
comprehensive range of child and adolescent diagnoses whose methodological properties are comparable
with other diagnostic instruments (Fisher et al., 1993; Shaffer et al., 1993).
However, findings pertaining to the DISC have not always been so favourable. In a study by Breton et al.
(1995) children's understanding of 280 DISC questions, pertaining to the most prevalent DSM-III-R
diagnoses, was evaluated. A total of 242 children were recruited from regular classes in four public
elementary schools in Montreal, Canada. Information from four children was used to cover one DISC
resulting in 60 DISCs, evenly distributed according to age and gender, being completed. Nonparametric tests
were used to assess understanding of questions as a whole, of time concepts (overall, categories, number),
and of questions based on the number of words.
Results indicated that children aged 9, 10, and 11 years understood 38%, 38%, and 42% of the questions as
a whole, respectively, and 26%, 24%, and 30% of the overall time concepts, respectively (Breton et al.,
1995). Shorter questions were significantly better understood than longer ones. Although the DISC has been
greatly improved since the initial version, the results suggest that additional revision is necessary before
clinicians or researchers use the DISC with younger children (Breton, et al., 1995).
Checklists:
Checklists completed by parents, such as the CBC or the ASI-4, take only 10-15 minutes to complete and
are an effective and efficient means of providing the clinician with a broad survey of emotional and
behavioural problems, some of which may be missed in a clinical interview (Tongue, 1998). This suggests
that checklists could prove useful in alerting the clinician to diagnostic areas warranting further pursuit.
Although the DSM is the most widely utilised diagnostic checklist it is not without its critics. For example,
because the DSMs are meant to be a 'way station' en route to more valid approaches, the DSM-IV
developers have "cautioned investigators and clinicians not to reify the diagnoses and taxonomic system"
(Jensen & Hoagwood, 1997, p. 232). Perhaps most importantly, the DSM approaches (e.g., the ASI-4) have
been appropriately criticised on the grounds of both over-and underinclusiveness, the potential for
misdiagnosis and misuse, and credibility (Jensen & Hoagwood, 1997; Wakefield, 1992). Compounding these
difficulties is the fact that revisions to the DSMs have occurred before sufficient research documenting the
usefulness and validity of the categories outlined in previous versions had been conducted (Jensen &
Hoagwood, 1997).
Interviews versus Checklists:

Researchers favouring one or the other methods have often justified their choice. For instance, Gadow and
Sprafkin (1997, p. 1) found the ASI-4 to be a valuable clinical tool because "it saves a lot of time and offers
an alternative to structured psychiatric interviews, which are too long, time consuming, and expensive for
standard clinical applications". However little empirical research has been conducted to investigate the
advantages and disadvantages of the two main approaches.
One recent study that has looked at this aspect is that by Boyle et al. (1997). This study investigated the
advantages and disadvantages of lay-administered structured interviews and self-administered problem
33
checklists for estimating the prevalence and associated features of six child and adolescent disorders. A
random sample of 2317 children aged 6 to 16 years was selected from public schools in an industrialised,
urban setting in Ontario, Canada. From this sample, data were obtained from the parental assessments of
251 children aged 6 to 16 years. Reliability and validity were compared between the DICA and the revised
Ontario Child Health Study scales (OCHS-R: Boyle et al., 1993). Reliability estimates were comparable for
the two instruments, however, the validity coefficients tended to marginally favour the checklist. Test-retest
reliability estimates of checklist scale scores versus the interview symptom counts were uniformly higher for
the checklist (Boyle et al., 1997). This led the researchers to state that the differences would appear to have
no discernible impact on the knowledge about prevalence and associated features of disorders generated by
such instruments in general population surveys (Boyle et al., 1997).
Therefore, Boyle et al. (1997) declared that the study found no scientific basis for choosing one particular
checklist over one particular interview in the context of a prevalence survey of child and adolescent
disorders. However, in light of this, Boyle et al. (1997, p. 793) continued to say that "checklists are less
expensive to use, take less time to administer, have few, if any, training requirements for administration, and
considerable flexibility of data collection". Although further investigation is needed, it would appear that
checklists are marginally preferable over structured interviews.
34
DEVELOPMENT OF THE INSTRUMENT FROM CONCEPTION
In order to successfully investigate the prevalence and comorbidity of child and adolescent disorders, it was
obvious that an effective screening instrument would need to be developed.
Requisite Characteristics of an Effective Screening Instrument:
In light of Boyle et al. (1997, p. 793) finding that "checklists are less expensive to use, take less time to
administer, have few, if any, training requirements for administration, and considerable flexibility of data
collection, a suitable checklist, rather than a semi-structured interview based system, is deemed desirable.
******************************
Almost all of the existing instruments pertaining to child and adolescent disorder had investigated only a
small number of disorders (e.g, 3-4). Therefore, the screening must contain criteria for a large number of the
most prevalent disorders (n≈20) in the one instrument. This will provide an effective screen for child and
adolescent disorder, as well as accounting for comorbidity implications.
******************************
Self-report can contribute greatly to an understanding of child and adolescent disorders, particularly so for
signs and symptoms that do not only describe observable behavioural manifestations, but are more closely
linked to internal emotional states, such as anxiety and depression (Weinstein et al., 1990).
More accurate results are achieved with the more informants, therefore, the screening instrument must
incorporate a Self-report, Parent-report, and Teacher-report Form.
******************************
The identification of disorders at as young an age as possible is extremely important for treatment options
because strong evidence exists that a large number of adolescent disorders have their origins in childhood.
For example, Rutter et al. (1976) found approximately 40% of disorders seen in adolescence had persisted
since childhood and the rest had newly developed during early adolescence.
Therefore, the screening instrument needs to contain wording that is simplistic in order to cater for children
as young as 10, whom Edelbrock et al. (1985) found to be reliable reporters.
******************************
Many of the existing checklists did not use recognised diagnostic criteria or investigate discrete disorders,
therefore, a suitable instrument must be based on widely regarded diagnostic criteria (e.g., DSM-IV).
******************************
Very few of the available checklists were validated against clinical judgement to ascertain the presence and
degree of the disorder (Offord et al., 1987). Therefore, clinical calibration during the validation stage is
deemed crucial.
******************************
35
ESTABLISHING THE DISORDERS TO BE INCLUDED IN THE INSTRUMENT
STUDY ONE: RELATIVE PREVALENCE

OF DISORDERS REFERRED TO SCHOOL PSYCHOLOGISTS
The purpose of Study One was exploratory in that it attempted to establish a list of child and adolescent
disorders which are encountered by teachers, and subsequently referred to school psychologists, in
mainstream primary and secondary school classes in Perth, Western Australia.
The aims of Study One were achieved through the completion of two phases. Phase One involved the initial
identification of child and adolescent disorders referred to school psychologists. Phase Two entailed the
construction and administration of a questionnaire investigating the Relative Prevalence of the disorders
identified in Phase One.
Phase One: Initial identification of disorders referred to school psychologists:

The purpose of Phase One was to establish a preliminary list of child and adolescent disorders which
teachers most often referred to school psychologists in mainstream classes in Western Australian schools.
Although it is acknowledged that parents are sometimes responsible for their children being referred to the
school psychologist, this is usually done through the teacher, rather than directly to the school psychologist.
Participants and setting:

The sample consisted of seven teachers (3 males and 4 females) and eight school psychologists (3 males
and 5 females) currently employed in primary and secondary schools in the Perth metropolitan area. All
participants have been working full-time for at least the past five years in both government and
nongovernment.
Procedure:
Each of the 15 individuals participating in Phase One was telephoned to arrange a suitable time for
interview. If participants wished, the interview was conducted during the initial telephone call. On initial
contact, each participant was informed that the researcher was attempting to develop a list of the child and
adolescent disorders encountered in mainstream classrooms. All participants were then asked the following
question: "Which child and adolescent disorders do you perceive to be found in Western Australian
mainstream primary and secondary classrooms?". Each telephone interview lasted approximately five
minutes.
Results and discussion:

The teachers (n=7) and the school psychologists (n=8) identified 18 specific child and adolescent disorders
as being found in mainstream primary and secondary schools. These disorders were termed, by the
researcher, in precise accordance with the DSM-IV and resulted in eight categories as shown in Table 2.
36
Table 2
Disorder categories and specific disorders identified by a selected group of experienced teachers
and school psychologists (n=15)
DSM-IV Disorder Category

Specific Disorders
1. Anxiety Disorders
1. Generalised Anxiety Disorder
2. Obsessive-Compulsive Disorder
2. Attention-Deficit and Disruptive Behaviour Disorders

3. Attention-Deficit/Hyperactivity Disorder
4. Conduct Disorder
5. Oppositional Defiant Disorder
3. Communication Disorders
6. Expressive Language Disorder
7. Mixed Receptive-Expressive Language Disorder
8. Phonological Disorder
4. Depressive Disorders
9. Dysthymic Disorder
5. Eating Disorders
10. Anorexia Nervosa
11. Bulimia Nervosa
6. Learning Disorders
12. Disorder of Written Expression
13. Mathematics Disorder
14. Reading Disorder
7. Pervasive Developmental Disorders

15. Asperger's Disorder
16. Autistic Disorder
8. Tic Disorders
17. Tic Disorder
18. Tourette's Disorder
37
Phase Two: Construction and administration of questionnaire:
The purpose of Phase Two of this study was to construct a questionnaire listing the child and adolescent
disorders identified in Phase One. This questionnaire (reproduced at end of Instumentation section), the
School Psychologist's Assessment of Referral Questionnaire (SPARQ: Langsford, Douglas, & Houghton,
1998a), was subsequently administered to a large sample of school psychologists to provide a more detailed
indication of the child and adolescent disorders referred to them by teachers in Western Australian primary
and secondary schools.
Participants and setting

The participants comprised a sample of 72 school psychologists currently working in primary and secondary
schools in Western Australia. Individuals were requested to complete the SPARQ in their work or home
setting, which ever was more convenient.
Instrumentation
The SPARQ comprises three separate sections. The first section requested participants to indicate if they
had received a referral from teachers in mainstream schools for any of the eight DSM-IV disorder categories
(shown in Table 2) during the past 12 months. If a student presented with two or more separate disorders
from different disorder categories, participants were asked to indicate them all. Furthermore, the participants
were requested to rank the eight DSM-IV disorder categories from "most referrals received" to "least referrals
received". These were later assigned numerical scores ranging from 8 (most referrals received) to 1 (least
referrals received).
The second section required participants to be more specific about the disorder categories for which they
had received at least one referral by indicating the specific disorder(s), within the category, for which
students had been referred.
In the third section, a space was provided for participants to indicate if there were any other disorders that
were not listed but for which they had received a referral during the past 12 months.
38
School Psychologist's Assessment of Referral Questionnaire
1. Please indicate if you have received a referral for any of the following disorder categories during the past
12 months. If a student presented with two or more separate disorders from different disorder categories,
please indicate them all. Furthermore, please rank the disorder categories from most referrals received (8) to
least referrals received (1).
tick rank tick rank
Attention-Deficit and Disruptive Behaviour Disorders Learning Disorders
Communication Disorders Pervasive Developmental Disorders
Depressive Disorders Tic Disorders
2. For the above disorder categories that you indicated receiving at least one referral, please be more
specific by indicating the individual disorder(s) for which students were referred.

Generalised Anxiety Disorder Anorexia Nervosa
Obsessive-Compulsive Disorder Bulimia Nervosa
Other

Attention-Deficit/Hyperactivity Disorder Disorder of Written Expression
Conduct Disorder Mathematics Disorder
Oppositional Defiant Disorder Reading Disorder

Expressive Language Disorder Asperger's Disorder
Mixed Receptive-Expressive Language Disorder Autistic Disorder
Phonological Disorder Other

Dysthymic Disorder Tic Disorder
Other Tourette's Disorder
3. Are there any other disorders that are not listed above for which you have received a referral during the
past 12 months? If so, please list them below.
(a) (b) (c)
39
Procedure:
A copy of the SPARQ and a letter providing information about the study were posted out to each school
psychologist in the quarterly mailout of the School Psychologists Association (SPA) of Western Australia
(n=135). Participants were asked to complete the questionnaire and return it to the researcher in the prepaid
envelope provided.

Of the 135 SPA members receiving the SPARQ, 72 completed questionnaires were returned which
represented a 53% return rate.
From the referral rankings provided by the school psychologists on the first section of the SPARQ, an initial
estimate of the prevalence of referrals of the general disorder categories was made. This was achieved by
determining the percentage of school psychologists who had received at least one referral in the past 12
months for each disorder category. In descending order, the percentage of school psychologists receiving at
least one referral in the past 12 months for each disorder category was: ADDBDs (95.83%); LDs (93.06%);
AnxDs (91.67%); DepDs (75.00%); ComDs (70.83%); PDDs (70.83%); EDs (55.56%); and TicDs (25.00%).
To provide a more accurate indication, the Relative Prevalence for each disorder category was calculated by
summing the cross-product of the number of school psychologists assigning each rank by the value of the
rank. For example, the Relative Prevalence value of 33 for TicDs was achieved by 9 school psychologists
ranking it as 1 (9x1=9), 4 ranking it as 2 (4x2=8), 4 ranking it as 3 (4x3=12), and 1 ranking it as 4 (1x4=4).
The referral rankings and subsequent totals awarded for each disorder category are shown in Table 3.
40
Table 3
Referral rankings from 1 (least referrals) to 8 (most referrals) as Relative Prevalence reported by school psychologists (n=72)
Rank
Least Referrals Most Referrals
no
DSM-IV Disorder Category rank 1 2 3 4 5 6 7 8 Relative
(%) Prevalence
Anxiety Disorders 8.33 0 0 4 12 26 13 3 8 353
Attention-Deficit and Disruptive Behaviour Disorders 4.17 0 0 0 2 1 11 31 24 488
Communication Disorders 29.17 0 2 6 3 7 25 8 0 275
Depressive Disorders 25.00 1 2 7 14 15 10 5 0 252
Eating Disorders 44.44 2 7 10 9 3 6 2 1 155
Learning Disorders 6.94 0 0 1 1 4 2 20 39 491
Pervasive Developmental Disorders 29.17 0 9 12 17 10 1 2 0 192
Tic Disorders 75.00 9 4 4 1 0 0 0 0 33
Total 2239
41
As shown in Table 3, the LD category had the highest reported Relative Prevalence (491) and the TicD
category had the lowest (33). The Relative Prevalence percentage referrals for each disorder category were
calculated and these are presented in Figure 1.
Tic (1.47%)
Pervasive Developmental (8.56%) Anxiety (15.74%)
Attention-Deficit
and Disruptive
Learning (21.89%)
Behaviour (21.76%)
Eating (6.91%)
Communication (12.26%)
Depressive (11.23%)
Figure 1: Percentage of total Relative Prevalence for each disorder category reported by school
psychologists.
As shown in Figure 1, the two most prevalent disorder categories, namely LDs and ADDBDs, together
represented 43.72% of all disorder referrals. Of the other categories, AnxDs, ComDs, and DepDs received
Relative Prevalence values in excess of 10%, whilst EDs, PDDs, and TicDs were all awarded Relative
Prevalence values of below 10%.
Section two of the SPARQ provided more specific information on the percentage of school psychologists
who had received a referral for each of the individual disorders within each category. These percentages are
shown in Table 4.
42
Table 4
Percentage of school psychologists reporting one or more specific disorder referrals (n=72)
DSM-IV Disorder Category DSM-IV Disorder Category

Specific disorder % Specific disorder %

Generalised Anxiety Disorder 72.22 Anorexia Nervosa 34.72
Obsessive-Compulsive Disorder 25.00 Bulimia Nervosa 31.94

Attention-Deficit/Hyperactivity Disorder 91.67 Disorder of Written Expression 65.28
Conduct Disorder 68.06 Mathematics Disorder 38.89
Oppositional Defiant Disorder 43.06 Reading Disorder 91.67

Expressive Language Disorder 55.56 Asperger's Disorder 55.56
Mixed Receptive-Expressive Language Disorder 47.22 Autistic Disorder 50.00
Phonological Disorder 50.00

Dysthymic Disorder 70.83 Tic Disorder 9.72
Tourette's Disorder 13.89
43
As shown in Table 5, the two most frequent specific disorder referrals were for RD (91.67%) and ADHD
(91.67%), with GAD (72.22%) third. Of all the disorders, only TicD was reported by school psychologists to
be less than 10%, while TD recorded 14%. The next lowest Relative Prevalence value was received by OCD
at 25%.
Section three of the SPARQ requested school psychologists to list any disorders for which they had received
a referral, but which were not included on the SPARQ. The most frequent disorders cited in this section were
BD, PTSD, and SAD. These disorders, however, were cited less than the least prevalent of the individual
disorders (TicD) included in the SPARQ. Therefore, from the results provided by the school psychologists, it
is evident that the disorders frequently referred to school psychologists from mainstream classes in Western
Australia were all included in the SPARQ. Nevertheless to ensure a comprehensive investigation, BD, PTSD,
and SAD will be included in any future research.
Section Summary:
Although Study One was exploratory in nature, it has demonstrated that, in this sample, there are 21
disorders which teachers most frequently encounter in mainstream classrooms, and which are subsequently
referred to school psychologists.
Of these disorders, two DSM-IV categories (ADDBDs and LDs) are responsible for almost half of all referrals.
With regards to specific disorders, a referral for ADHD and RD were both received by 91.67% of the school
psychologists in the past 12 months.
There was a substantial drop to GAD which was the third highest with 72.22%.
When given the opportunity to identify additional disorders (which were not included in the SPARQ), school
psychologists cited only three (BD, PTSD, and SAD), and these were of low Relative Prevalence.
44
STUDY TWO: CONSTRUCTION AND VALIDATION OF A
SCREENING INSTRUMENT FOR CHILD AND ADOLESCENT DISORDERS
Study Two of this research involved the construction and validation of an appropriate screening instrument
comprising the 21 disorders identified in the previous study. This was achieved through two separate, yet
inter-related phases as follows.
Phase One involved the construction of an initial screening instrument for the 21 child and adolescent
disorders identified in the previous study. This instrument was named the Child and Adolescent Disorder
Screening Instrument (CADSI: Langsford, Houghton, & Douglas, 1998) and consisted of three separate, yet
commensurate, screening forms (the Self-report Form, Parent-report Form, and Teacher-report Form). Each
form comprises DSM-IV diagnostic criteria for the respective disorders identified in the previous. Also
incorporated into each Form were seven repeat items to provide a measure of rater reliability.
In Phase Two of this study a validation of the CADSI was conducted. This validation process involved an
analysis of the readability level of the CADSI Self-report Form, an analysis of the agreement of responses
across the three forms, and a clinical verification of the disorder criteria.
The readability analysis was performed to determine the youngest age at which the language of the CADSI
was deemed appropriate. The agreement analyses provided evidence that participants were able to respond
to the items of the CADSI in a reliable fashion. The clinical calibration test involved a clinic sample of children
and adolescents representing various disorders (formally diagnosed by paediatricians), completing the
CADSI. The sensitivity of the CADSI was then determined for each disorder by comparing the formal clinical
diagnosis of each child with the CADSI screening cutoff for that disorder.
Phase One: Construction of a screening instrument for child and adolescent disorders:
The purpose of Phase One of this study was to construct an instrument for the initial screening of the 21
disorders for which school psychologists, in the previous study, received the most referrals. Each of these 21
disorders contained within the instrument was represented by a number of DSM-IV behavioural criteria
relating to that disorder. If a participant's responses exceeded a designated number of criteria (the screening
cutoff) for a disorder they were deemed to be a positive screen for that disorder.
It is important to note that a positive screen is not a diagnosis, as a formal diagnosis for these disorders can
only normally be made by paediatricians, psychiatrists, clinical psychologists, or neurologists. A positive
screen merely indicates that the individual has met sufficient criteria for a disorder to warrant further
investigation by an appropriate professional.
Procedure, results, and discussion:

The CADSI was modelled on the ASI-4 (Adolescent Symptom Inventory; Gadow & Sprafkin, 1994), however,
several significant and distinct alterations were made. For example, the ASI-4 is completed by the parent
and/or teacher whereas the CADSI is completed by the child or adolescent (Self-report Form), the primary
caregiver (Parent-report Form), and the teacher (Teacher-report Forms). Both the Self-report Form and the
Parent-report Form contain 136 items, identical apart from the different terminology; for example, "I have..."
(Self-report Form) versus "Your child..." (Parent-report Form). The Teacher-report Form consists of a subset
of 98 items from the Self-report Form and the Parent-report Form with each item beginning with "This
student...". The Teacher-report Form consists of less items because all of the criteria for Anorexia Nervosa
(AN), SAD, and BN, and some items of Posttraumatic Stress Disorder (PTSD), CD, and DD are not likely to
be answered reliably by teachers due to the behaviours occurring predominantly outside of school; for
example, sleeping habits and eating habits.
Thirteen of the 24 disorders in the ASI-4 were identified in Study One and were, therefore, considered for
inclusion in the CADSI. These were: GAD, OCD, PTSD, SAD, ADHD, CD, ODD, BD, DD, AN, BN, TicD, and
TD. The ASI-4 is designed for adolescents aged 12 to 18 years, whereas the CADSI is designed for children
and adolescents aged between 10 and 17 years. In order to ensure that the instrument was suitable for this
intended age range, two primary school principals were asked to identify items contained within the
instrument that were deemed of inappropriate content for young children. Three CD items were identified by
the school principals and were subsequently removed. These items referred to behaviours indicating forced
sexual activity, breaking and entering, and the deliberate lighting of fires.
For the remaining disorders identified in Study One, the items for Asperger's Disorder (AsD) and Autistic
Disorder (AD) were adapted directly from the Child Symptom Inventory-4 (CSI-4: Gadow & Sprafkin, 1994)
and the items for the ComDs (Expressive Language Disorder [ELD], Mixed Receptive-Expressive Learning
45
Disorder [MRELD], and Phonological Disorder [PD]) and LDs (Disorder of Written Expression [DWE],
Mathematics Disorder [MD], and Reading Disorder [RD]) were based on diagnostic features provided in the
DSM-IV. For example, the DSM-IV (p. 50) states that "A number of skills may be impaired in mathematics
disorder, including linguistic skills (e.g., understanding or naming mathematical terms, operations, or
concepts...). Therefore, an item for MD stating that "I have trouble understanding or naming mathematical
terms, operations, or concepts" (Self-report Form, item 107) was incorporated into the CADSI.
The response options for BD and DD were changed from Yes/No (as in the ASI-4) to a four-point ordered
scale to make the instrument consistent throughout. Seven items within the CADSI were randomly selected,
slightly reworded, and repeated in random positions to provide a measure of rater reliability. For example,
Item 14, "I get tense and cannot relax" was repeated as Item 40, "I get uptight and cannot relax".
Unlike the ASI-4, items for each of the disorders were randomly allocated throughout the CADSI. This was
achieved by generating a random number series using SPSS 6.1 (SPSS, 1994). In many cases the wording
or spelling was changed from American to Australian terminology, for example, check to tick, plays hookey to
'wags', liquor to spirits, real to really, behavior to behaviour, organizing to organising, etc.
Scoring of the Child and Adolescent Screening Instrument:

Participants are required to shade, with pencil, the circle that best represents the frequency of their
behaviours (i.e., Never, Sometimes, Often, or Very Often). Shading of the circle is required because the
CADSI was constructed in a such a format that it allows the scoring of items to be performed by a scanner.
Scoring of the items for all three Forms of the CADSI is based on the frequency of the child or adolescent's
behaviour with all items scored as follows: Never = 0, Sometimes = 1, Often = 2, and Very Often = 3.
When calculating disorder screening scores the items for all categories, with one exception, are recoded as
follows: Never = 0, Sometimes = 0, Often = 1, and Very Often = 1. These values were chosen because
although many people with and without disorders may exhibit similar behaviours, it is the frequency of the
behaviour that is important. The one exception is for CD where seven of the behaviours (e.g., fighting with a
weapon, stealing) are considered to be so severe that 'Sometimes' is also awarded a score of 1
(Lagenbucher, Morgenstern, Labouvie, Miller, & Nathan, 1996). Therefore, the summation of the items within
each disorder produces a screening score for that disorder, which if exceeding the screening cutoff score,
designates the individual as a positive screen for that disorder.
Phase Two: Validation of the Child and Adolescent Disorder Screening Instrument:
The purpose of Phase Two of this study was to investigate the psychometric properties of the items within
the CADSI, in particular the content and concurrent validity. This was achieved through three separate
stages; Stage One: Investigation of the readability of the instrument; Stage Two: Analysis of rater reliability
and agreement between participants; and Stage Three: Verification of the sensitivity of the disorder criteria.
Stage One: Investigation of the readability of the instrument:

The purpose of Stage One was to establish whether the language used within the CADSI was suitable for
young children. This was achieved by subjecting the instrument to a computerised readability analysis, as
well as testing its content validity with a small group of Year 5 children (9-10 years old).

Participants involved in the first stage of the CADSI validation comprised 20 students (13 males and 7
females) from two Year 5 classes from one state government primary school. These students were identified
by their classroom teachers, and confirmed by the deputy principal, as being of low-to-middle English ability.
These children subsequently participated in focus group interviews in a room made available by the school.

The first task in evaluating the suitability of the instrument was to subject it to a 'Readability Analysis' using
the grammar analysis on Microsoft Word 5.1 (Microsoft, 1992). This analysis provided the instrument's
Flesch Reading Ease and Flesch-Kincaid Grade Level.
The Flesch Reading Ease reports the average number of words per sentence and the average number of
syllables per 100 words. Standard writing averages 17 words per sentence and 147 syllables per 100 words.
Scores range from 0 to 100, with standard writing averaging between 60 and 70. The higher the score, the
greater the number of people who can readily understand the document.
46
The Flesch Reading Ease for the CADSI was calculated at 80.9, which is well above the standard writing
average of 60 to 70, indicating that the wording of the CADSI is quite suitable for young children.
The Flesch-Kincaid Grade Level is a measure of readability based on the average number of syllables per
word and the average number of words per sentence. The score indicates an educational grade level. For
example, a score of 8.0 means that an average Year 8 student would understand the text. Standard writing
approximates to the seventh-to-eighth grade level.
The Flesch-Kincaid Grade Level for the CADSI was calculated at 3.9 which indicates that the instrument is
suitable for children in Grade 4 or above. This grade level is based on American children, who in each grade
are a year older than their Australian counterparts, so the instrument was deemed appropriate for children in
Years 5 and above (i.e., 10 years of age and above).
Despite these analyses indicating that the CADSI possesses appropriate readability for Years 5 and above, it
was thought necessary to check the wording with a small group of Year 5 children in order to identify any
words that may be misunderstood, and thereby, lower the instrument's content validity.
Two separate focus group interviews, each with 10 Year 5 students considered by their classroom teachers
to be of low-to-middle English ability, were conducted. The researcher provided each participant with a copy
of the questionnaire and proceeded to read slowly through the questionnaire, focusing on the more difficult
words. When any of the participants indicated that they were unsure of the meaning of a sentence or word
the rest of the group was asked if they too were unsure. If no-one else was confused about the meaning no
alterations were made. If more than one participant indicated confusion, the group were asked to identify
another word which would be more clearly understood. If this was not forthcoming, where possible, the word
was deleted. Only three minor wording changes were necessary for the following words: laxatives, binges,
and unrealistic. These changes did not effect the original values for the Flesch Reading Ease and the
Flesch-Kincaid Grade Level.
Stage Two: Analysis of the agreement between responses:

The purpose of Stage Two was to establish whether children and adolescents are able to reliably self-report
their own behaviour. This was achieved by investigating each participant's agreement of responses across
the seven repeated items. Furthermore, the pair-wise agreement of ratings between the three groups (Self-
reports, Parent-reports, and Teacher-reports) was also investigated for the corresponding items of the
respective CADSI Forms (Self-report Form/Parent-report Form = 136 pairs, Self-report Form/Teacher-report
Form = 98 pairs, Parent-report Form/Teacher-report Form = 98 pairs.
Participants:
Participants involved in the second stage of the CADSI validation comprised 823 students (385 males and
438 females) from each of Years 5 (n=97) and 7 (n=91) from four state government primary schools and
from Years 9 (n=393) and 11 (n=242) from six state government secondary schools. These schools were
situated in diverse areas which resulted in participants from three SES areas; namely low (n=303), middle
(n=440), and high (n=80). The participants ranged from 10 to 18 years of age.
Setting:
All participants completed the CADSI uninterrupted in their classroom at their respective school. Students
not involved in the study were instructed by their teacher that they were permitted to silent read or begin their
homework while the others completed the instrument. A test environment was established to reduce the
amount of noise and interaction between students.

A number of schools were contacted by the researcher and informed of the content and the purpose of the
research. Nine schools were selected based on their geographical and SES area. A parental consent form
was posted to all parents of children in each of Years 5, 7, 9, and 11 from each of the participating schools.
This consent form consisted of information pertaining to the research and asked parents for permission for
their child(ren) to be involved in the study.
It was stressed to the parents, teachers, and students that all data collected were confidential, and that no
information would be made available to other sources without parental permission. The parental consent
form used in this stage of the study has been reproduced as Appendix J.
Classroom teachers distributed the CADSI to the participants during a regular class period. On completion of
the CADSI, students placed their questionnaires in an envelope which was sealed to ensure confidentiality,
and then handed in to the teacher. The researcher subsequently collected all completed questionnaires.
47
The data from each of the completed CADSIs were entered into an SPSS 6.1 datasheet. In order to test for
the agreement of the responses of the individual participants, the responses to the seven repeated items
were extracted and matched with their corresponding repeat.
Several statistical procedures are available for the testing of agreement between two ordinal variables: rho
(Spearman, 1906), tau (Kendall, 1938; 1962), gamma (Goodman & Kruskal, 1954), and the C ordinal
statistic (Cicchetti, 1972). All of these procedures were considered for the testing of agreement, however,
none was found to be appropriate for the required analyses. Cicchetti (1972, p. 17) stated that "perhaps in
part due to the unknown nature of the exact distribution of rho, Kendall's tau has been the statistic of choice".
However, tau is afflicted by one very serious limitation in that it merely reports to what extent the rankings of
the same items are in the same order, without taking into account the distance between any paired items.
Therefore, according to Cicchetti (1972, p. 17), "two different sets of ordinal data will produce identical
results, provided only that the ordering of each set of rankings is consistent". Gamma was seen as an
inappropriate alternative due to its underlying assumption of the absence of ties (Agretsi, 1984; Cliff, 1996;
SPSSx, 1986). Since the CADSI comprises items which are responded to on a four-point ordinal scale,
multiple ties were expected. The statistic that proved closest to what was required was the C ordinal statistic.
However, the C ordinal statistic is restricted to values between 0 and 1, which does not allow sufficient range
for effective discrimination.
Since each of the above procedures is limited in some manner it was deemed necessary to develop a new
statistical procedure for testing agreement among ordered items. Therefore, during this study the agreement
between all CADSI pairs was examined using a newly developed statistic termed Omega (Ω: Douglas,
Langsford, & Houghton, 1998). Omega is a rank-ordered statistic that applies weights which reflect the level
of agreement/disagreement between two items on ordered scales. The weightings assigned reflect the
number of available response options for each ordered scale.
The general formula for Omega is defined as:

k-1
Ω=1 Zo - ∑ Zi i
n i=1 k-1
where:
n= Number of paired items
Zo= Number of pairs answered exactly
Zi= Number of pairs answered disagreeing by at least 1
k= Number of available response options
Therefore, Omega has a range from 1 (total agreement) to -1 (total disagreement) where the greater the
value of Omega, the better the agreement of the responses. Two disparate examples of the Omega analysis
for the four-point ordered scale used in the CADSI are provided below as Example 1 and Example 2.
Example 1
Example of Omega for a four-point ordered scale involving seven paired items
A participant responding to the seven repeat CADSI reliability pairs as (0,0), (1,1), (2,2), (1,3), (1,1), (1,2),
and (3,3) is clearly perfectly consistent on 5 of the 7 items and is out by 1 on one other and by 2 on the
remaining item. Therefore, the Omega value is determined as follows:
k-1
Ω=1 Zo - ∑ Zi i
n i=1 k-1
Ω = 1/n[Zo - {Z1(1/3) + Z2(2/3) + Z3(1)}]

Ω = 1/7[5 - {1(1/3) + 1(2/3) + 0(1)}]
Ω = .57
Example 2
Example of Omega for a four-point ordered scale involving seven paired items
A participant responding to the seven CADSI reliability pairs as (0,2), (2,1), (2,2), (1,3), (3,1), (1,2), and (0,3)
would receive an Omega value as follows:
Ω = 1/7[1 - {2(1/3) + 3(2/3) + 1(1)}]

Ω = - .38
48
In order to determine an Omega cutoff score (for n=7 and k=x), which separates the participants deemed to
have provided reliable responses from those that have not, 5000 random cases were generated using SPSS
6.1 and subjected to the Omega statistical procedure. The cutoff value for the reliability measure was
determined to be the Omega value at the 90th percentile for the 5000 random generated pairs. The Omega
value at the 90th percentile for the four-point ordered scale involving the 7 repeat items in the CADSI was
calculated to be .19. The distribution of the 5000 random cases is provided in Figure 2.
49
1200
Mean (-.17)
N 1000
o
800
o
f
600 90th percentile (.19)
C
95th percentile (.29)
a 400
s
e
99th percentile (.52)
s 200
0
-1.00 -.75 -.50 -.25 0.00 .25 .50 .75 1.00
Omega value
Figure 2: Frequency distribution of Omega for 5000 randomly generated cases
on a four-point ordered scale involving seven matched items.
50
It is evident from Figure 2 that the Omega distribution for a four-point scale displays a positive skew rather
than a normal distribution. However, the resulting cutoff value (Ω=.19) of this Omega distribution closely
reflects the arbitrary cutoff for the most widely used agreement statistic for nominal scales, the Kappa
coefficient (Cohen, 1960), outlined in Landis and Koch (1977) and provided as Table 5.
Table 5
Arbitrary cutoffs for Kappa Coefficient (Landis & Koch, 1977)
Kappa Statistic Strength of Agreement
<.00 Poor
.00-.20 Slight
.21-.40 Fair
.41-.60 Moderate
.61-.80 Substantial
.81-1.00 Almost Perfect
Therefore, for the purpose of this study, participants who received an Omega value for the CADSI reliability
scale below the .19 cutoff, (like the individual in Example 3), or who failed to answer four or more item pairs,
were removed from the sample. This resulted in 119 participants being removed, thus leaving a reliable
sample (mean Ω =.61, sd =.21, >99th percentile) comprised of 704 children and adolescents (313 males and
391 females) from each of Years 5 (n=76) and 7 (n=85) from four primary schools, and from Years 9 (n=341)
and 11 (n=202) from five secondary schools. These schools were designated a SES classification (i.e., low,
medium, and high) according to Australian Bureau of Statistics (ABS: Broom, Duncan-Jones, Lancaster-
Jones, McDonnell, 1977) demographic location. Therefore, this sample comprised 261 participants from low
SES areas, 372 from middle, and 71 from high. Although classification of SES has been conducted in this
manner, it is acknowledged that classification of SES on a school-by-school basis may result in a small
number of students attending school in a contrasting SES area than that in which they live. Hence, ensuing
results should be interpreted with this in mind.
Of these 704 participants, a small number of parents and teachers were asked to fill out the respective
CADSI forms in order to provide a comparison between the ratings assigned by the self-report participant of
his/her behaviour and the ratings provided on his/her behalf by their parent and teacher. Therefore, a
parental consent form (reproduced as Appendix K) was sent to the parents of a randomly selected 15%
(105) of the sample. Furthermore, a second randomly selected 15% (105) of the original sample was chosen
for rating by their teacher .
Forty-eight Parent-report Forms and 52 Teacher-report Forms were returned and matched using the
biographical data provided on each Form. This represented a 46% response rate for the parents and a 49%
response rate for the teachers. Seventeen Self-report participants were matched with both a Parent-report
and Teacher-report Form.
As no names were required on the CADSIs, biographical information was used to match the respective
Forms as follows: date of birth, age, gender, grade, and school code. Forms were automatically discarded if
two Self-report Forms presented with the same biographical information (for instance, two people with the
same birth date, in the same grade, and at the same school).
To determine the level of agreement between the respective groups, in relation to behavioural rating using
the CADSI, the mean Omega value was calculated between the three groups' corresponding items (i.e. Self-
report/Parent-report (n=136 pairs), Self-report/Teacher-report (n=98), and Parent-report/Teacher-report
(n=98).
Once again, in order to determine Omega cutoff scores for the varying agreement analyses, 5000 random
cases were generated and subjected to a series of Omega statistical procedures. These involved Omega
distributions for 136 paired items on a four-point (Self-report versus Parent-report raw data) and two-point
(Self-report versus Parent-report coded data) ordered scale. Similarly, Omega distributions were calculated
for 98 paired items on a four-point (Self-report versus Teacher-report raw data, and Parent-report versus
Teacher-report raw data) and two-point (Self-report versus Teacher-report coded data, and Parent-report
versus Teacher-report coded data) ordered scale.
51
The cutoff value selected to indicate agreement between the raters was set at the 90th percentile for the
5000 random generated pairs. The Omega value at the 90th percentile for the four-point ordered scale was -
.07 for the 136 paired items (Self-report/Parent-report) and -.06 for 98 paired items (Self-report/Teacher-
report; Parent-report/Teacher-report). The Omega value at the 90th percentile for the two-point ordered
scale (coded and screen data) was calculated to be .12 for both the 136 paired items and the 98 paired
items. The Omega distributions and relevant percentiles for these 5000 random generated cases are
provided as Appendixes L, M, N, and O, respectively.
The Omega values for the frequency of the individual behaviours were analysed using both raw data (rated
0-3), coded data (0-1), and screen data (0-1). The results of these Omega analyses are provided in Table 6.
52
Table 6
Mean (and standard deviation) of Omega between the self-report, parent-report, and teacher-report groups
Parent-report (n=48) Teacher-report (n=52)

Mean Omega (standard deviation) Mean Omega (standard deviation)
Raw (0-3) Coded (0-1) Screen (0-1) Raw (0-3) Coded (0-1) Screen (0-1)
Self-report
Raw (0-3) .23 (.20) .11 (.23)
Coded (0-1) .52 (.25) .45 (.29)
Screen (0-1) .77 (.19) .71 (.22)
Parent-report
Raw (0-3) .37 (.22)
(n=17)
Coded (0-1) .77 (.31)

(n=17)
Screen (0-1) .93 (.18)

(n=17)
53
As shown in Table 6, the level of agreement between all three groups is deemed to be substantial (mean Ω
all above the 99th percentile). The lowest level of agreement was found between the Self-report and the
Teacher-report raw data (mean Ω=.11). This may be due to the teacher not knowing the student as well as
the parents, especially in secondary school (a large portion of the sample) where each student has multiple
teachers for relatively short periods of time. The second lowest level of agreement was between the Self-
report and Parent-report raw data (mean Ω=.23). This may be due to the parents being unaware of all of the
behaviours that their children are involved in. Despite these discrepancies, the results indicate that the child
and adolescents' self-reports are consistent with the observations of their parents and teachers, and
therefore, capable of accurately rating their own behaviour.
Stage Three: Clinical calibration of the Child and Adolescent Disorder Screening Instrument:
Stage Three of the validation phase involved an investigation of the CADSI in terms of the clinical calibration
of the disorder criteria. This clinical calibration refers to the sensitivity (or convergent validity) of the
instrument to successfully report the respective screen for which the children and adolescents have received
a clinical diagnosis by paediatricians. This was achieved by establishing, within a clinic sample, the level of
agreement between self-report data and paediatric diagnosis, and parent-report data and paediatric
diagnosis, for each of the individual disorders contained within the CADSI.

The participants in this stage comprised 64 (44 males and 20 females) clinically diagnosed (with a range of
disorders) children and adolescents aged between 10 and 17 years, and their primary caregivers. Each
participant (child and caregiver) completed the CADSI in their home setting.
Procedure:
Envelopes (each containing a CADSI Self-report Form, CADSI Parent-report Form, reply paid envelope, and
consent form) were posted to each of the collaborating paediatricians for distribution among potential
participants. Each paediatrician was asked to send an envelope (containing the Forms) to five children or
adolescents (aged 10-17 years) with one of the 21 disorders contained within the CADSI. ADHD and TicD
were divided into their subtypes, thereby creating 24 individual disorders for investigation. The paediatricians
were requested to place a code (1-24) on each of the reply paid envelopes which corresponded with the
particular diagnosed disorder. The paediatricians were also informed that comorbidity was not an issue, as
each child would be involved in the calibration of one disorder only.
The consent form consisted of information pertaining to the research and a request for the child and the
primary caregiver to complete the enclosed Forms. Participation was on a voluntary basis with the option of
returning the Forms incomplete. The parental consent form for the paediatric sample is reproduced as
Appendix P.

This stage aimed to determine whether a sample of children and adolescents clinically diagnosed by
paediatricians would be found to have the same CADSI positive screen. Sixty-four pairs (self-report and
parent-report) of completed CADSI Forms were returned. Due to the respective professionals being involved
in the distribution of the CADSI, it is not possible to provide a response rate percentage for this stage of the
study. The number of agreements for each positive screen is provided in Table 7.
54
Table 7
Number of agreements between paediatric diagnosis, self-report, and parent-report
Paediatric Self-report Parent-report

Disorder Diagnosis Agreement Agreement
GAD 5 0 1
OCD 5 2 3
PTSD 3 3 3
SAD 1 1 1
ADHD-I 5 2 5
ADHD-HI 5 1 3
ADHD-C 5 1 1
CD 2 1 1
ODD 4 3 4
BD 0 - -
ELD 1 1 1
MRELD 1 0 0
PD 2 1 1
DD 3 2 1
AN 0 - -
BN 0 - -
DWE 4 3 4
MD 3 1 3
RD 3 2 3
AsD 2 1 1
AD 0 - -
TicD-M 3 3 3
TicD-V 2 1 2
TD 5 3 5
Total 64 32/64 46/64

Percentage
Agreement 50.00% 71.88%
55
Table 7 indicates that the sensitivity of the CADSI varies according to individual screen and source of report
(i.e., self-report vs parent-report). Overall, the percentage of agreement between the paediatric diagnosis
and the CADSI screen for self-report was 50.00% (32/64), and 71.88% (46/64) for the parent-report. Perfect
agreement was found between the paediatric diagnosis and self-report screen for PTSD, SAD, ELD, and
motor tic disorders (TicD-M). Similarly, perfect agreement was found between the paediatric diagnosis and
parent-report screen for PTSD, SAD, ADHD-I, ODD, ELD, DWE, MD, RD, TicD-M, vocal tic disorders (TicD-
V), and TD. This high level of agreement, especially with the parent-report, indicates that the CADSI disorder
criteria can be considered to be commensurate with clinical diagnosis.
Incidences of low level agreement (e.g., ADHD-HI, GAD) may be attributed to a number of factors. First,
because of the small sample size, each disagreement within individual screens take on greater magnitude
(e.g., 1 disagreement out of 3 = 33.33% disagreement). Second, not all of the paediatricians involved in this
study use DSM-IV criteria for diagnosis. Some use other systems such as the ICD-10, or rely on their
"professional intuition" acquired over 30 years of experience. Third, clinically referred children tend to
possess greater severity of disorder symptoms, and hence find it more difficult to rate their own behaviour.
Fourth, clinic samples exhibit more comorbidity than mainstream samples, therefore, a combination of
disorders (e.g., ADHD & ODD) may be misinterpreted for another related disorder (e.g., CD). Fifth, a
combination of two or more specific disorders (e.g., PTSD & SAD) may be identified as GAD. Sixth, gender
differences may influence diagnosis, for example, a female would be more likely to be diagnosed with ODD
rather than the more severe CD.
Chapter summary:
The primary objective of this chapter was concerned with the construction and validation of an appropriate
screening instrument comprising the 21 disorders for which school psychologists in Study One reported
having the most referrals. The resulting instrument (the CADSI) incorporates three separate Forms: The
CADSI Self-report Form, CADSI Parent-report Form, and CADSI Teacher-report Form. Both the Self-report
Form and the Parent-report Form are seven pages in length and comprise 136 questions. One hundred and
seventeen questions address the 21 individual disorders, while 12 questions assess the child or adolescents'
levels of Self-Control. Of the questions relating to disorders, seven are repeat questions in order to provide
an estimate of each participant's accuracy of responding. The Teacher-report Form is five pages in length
and comprises 98 questions. Seventy-nine questions address 18 individual disorders (no SAD, AN, or BN),
while 12 questions assess the child or adolescents' level of Self-Control. Seven repeat questions are
incorporated in order to provide an estimate of each participant's accuracy of responding.
The CADSI comprises statements that participants respond to on a four-point ordered scale anchored with
'Never' to 'Very Often'. Scoring of the items for all forms of the CADSI is based on the frequency of the child
or adolescent's behaviour with all items scored as follows: Never = 0, Sometimes = 1, Often = 2, and Very
Often = 3. If a participant's criterion score exceeds the screening cutoff score for a disorder then the
individual is awarded a positive screen for that disorder. It is important to note that a positive screen does not
imply a diagnosis. It merely suggests that the individual has met enough criterion to warrant further
investigation.
The CADSI was subjected to a rigorous psychometric analysis and was found to be reliable and valid for
Years 5 and above. Therefore, the CADSI is deemed suitable for the investigation of the prevalence and
comorbidity of child and adolescent disorders.
56
FURTHER DEVELOPMENT OF THE INSTRUMENT – RENAMED THE psychprofiler
After many years of use the widespread use, the CADSI underwent some further refinement and was
renamed the child and adolescent psychprofiler.
Furthermore, an adult version was created and named the adult psychprofiler.
Wording changes:
Slight wording changes were performed to further improve the validity and reliability of the instrument.
Both the child and adolescent psychprofiler and adult psychprofiler were subjected to a 'Readability
Analysis' using the grammar analysis on Microsoft Word XP (Microsoft, 2004). This analysis provided a
number of statistics, most importantly the instrument's Flesch Reading Ease and Flesch-Kincaid Grade Level
and are presented in Tables 8 and 9.
Table 8
Readability statistics of the self-report child and adolescent psychprofiler
CAPP Self-report Statistics

Number of Words 1036
Number of Characters 4496
Number of Sentences 111
Average Number of Words per Sentence 9.3
Average Number of Characters per Word 4.1
Flesch Reading Ease 78.3
Flesch-Kincaid Grade Level 4.6
Table 9
Readability statistics of the self-report adult psychprofiler
APP Self-report Statistics

Number of Words 2304
Number of Characters 11476
Number of Sentences 190
Average Number of Words per Sentence 12.0
Average Number of Characters per Word 4.7
Flesch Reading Ease 58.2
Flesch-Kincaid Grade Level 8.1
The Flesch Reading Ease reports the average number of words per sentence and the average number of
syllables per 100 words. Standard writing averages 17 words per sentence and 147 syllables per 100 words.
Scores range from 0 to 100, with standard writing averaging between 60 and 70. The higher the score, the
greater the number of people who can readily understand the document.
The Flesch-Kincaid Grade Level is a measure of readability based on the average number of syllables per
word and the average number of words per sentence. The score indicates an educational grade level. For
example, a score of 8.0 means that an average Year 8 student would understand the text. Standard writing
approximates to the seventh-to-eighth grade level.
The Flesch Reading Ease for the CAPP was calculated at 78.3, which is well above the standard writing
average of 60 to 70, indicating that the wording of the CAPP is quite suitable for young children.
The Flesch-Kincaid Grade Level for the CAPP was calculated at 4.6 which indicated that the instrument is
suitable for children in Grade 4½ or above. This grade level is based on American children, who in each
57
grade are a year older than their Australian counterparts, so the instrument was once again deemed
appropriate for children in Years 5 ½ and above (i.e., 10 years of age and above).
Analysis of the APP wording indicated that the Flesch Reading Ease was 58.2 and the Flesch-Kincaid Grade
was 8.1 which indicated that the instrument is suitable for adults with a reading at a grade level of 8 or
above. Once again. As this grade level is based on American children, who in each grade are a year older
than their Australian counterparts, the APP was deemed appropriate for adults with a reading level of Grade
9 and above.
Australian schooling is compulsory until the end Grade 10, therefore, the wording of the APP was deemed
suitable for most adults.
Scale Development:
The original instrument, the CADSI, required respondents to indicate their frequency of each behaviour on a
4-point Likert scale (i.e., Never, Sometimes, Often, or Very Often).
Once again, to improve the validity and clinical sensitivity of the instrument, the scale employed for the
psychprofiler was extended to a 6 point scale (i.e., Never, Rarely, Sometimes, Regularly, Often, or Very
Often).
When calculating disorder screening scores the majority of items are recoded as follows: Never = 0, Rarely =
0, Sometimes = 0, Regularly = 1, Often = 1, and Very Often = 1.
The exceptions are for selected behaviours of Conduct Disorder, (e.g., fighting with a weapon, stealing),
Panic Disorder (e.g., sudden onsets of fear), Major Depressive Disorder (e.g., suicide), Antisocial Personality
Disorder (e.g., criminal acts), and TicD-V/M (e.g., rapid, nonrhythmic behaviours) where the behaviours are
considered to be of sufficient severity that 'Sometimes' is also awarded a score of 1 (Lagenbucher,
Morgenstern, Labouvie, Miller, & Nathan, 1996).
Qualitative Information:
Space has been provided for the respondent to write any information that they feel may be useful to the
health professional.
These changes have further enhanced the psychprofiler and is proving to be an important instrument in the
improvement of assessment and treatment of children and adults throughout Australia
58
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Psych Profiler Manual

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Phone: (08) 9388 8044

PO Box 502 SUBIACO

© Langsford1, Houghton2, & Douglas3 (2005)

psychprofiler software developed by Strategy West Consulting

Author Information viii

Software development viii

Completion and Scoring Procedures 2

Validity and Reliability 3

Ways in Which the psychprofiler Can Improve Assessment and Treatment 11

Theoretical Basis of the Instrument 14

Strengths and limitations of interviews and checklists 33

Development of the Instrument from Conception 35

Establishing the Disorders to be Included in the Instrument

Phase One: Initial identification of disorders referred to school psychologists 36

Phase Two: Construction and administration of questionnaire 38

2 Disorder categories and specific disorders identified by a selected group of experienced

3 Referral rankings from 1 (least referred) to 8 (most referred) as Relative Prevalence

5 Arbitrary cutoffs for Kappa Coefficient (Landis & Koch, 1977) 51

7 Number of agreements between paediatric diagnosis, self-report, and parent-report 55

8 Readability statistics of the child and adolescent psychprofiler 57

9 Readability statistics of the adult psychprofiler 57

1 Percentage of total Relative Prevalence for each disorder category reported by

2 Frequency distribution of Omega for 5000 randomly generated cases on a four-point

ABS: Australian Bureau of Statistics

psychprofiler (Langsford, Houghton, & Douglas, 2005)

*** not included in the CAPP ** not included in the APP

COMPLETION AND SCORING PROCEDURES

Each report generated by the psychprofiler software includes the following:

(a) Cover page

Each assessment using the psychprofiler allows you to:

© Langsford1, Houghton2, & Douglas3 (2005)

Name: Justin Example Gender: Male

Address: 308 Hay Street Date of Birth: 12 May 1972

Phone: (08) 9388 8044 Age at Completion: 32

Observer: Justine Example Completion Date: 23 June 2004

Disorder Positive Self Observer Positive Screen Items Met

Bulimia Nervosa >=4 1 1 NO

Asperger's Disorder (#4) >=2 0 1 NO

Autistic Disorder (#4) >=2 0 1 NO

Tic Disorder-Vocal (#5) >=1 0 0 NO

Number of Positive Screens 4 4

© Unauthorised use or reproduction of this report is not permitted.

Positive Screen Cutoff Column

Self-Report Score Column

Observer-Report Score Column

Cutoff Attained Column

Positive Screen Items Met Column

Posttraumatic Stress Disorder

Separation Anxiety Disorder

Attention-Deficit and Disruptive Behaviour Disorders:

Oppositional Defiant Disorder:

Mixed Receptive-Expressive Language Disorder:

Major Depressive Disorder:

Pervasive Developmental Disorders:

psychprofiler Software Program:

Online Versions of the psychprofiler:

Increased Early Identification and Intervention

Provision of Objective and Reliable Data

Optimises the Efficiency of Clinical Interviewing

* not included in the CAPP not included in the APP