Clinical Decision Making About Child and Adolescent Anxiety Disorders Using the Achenbach System of Empirically Based Assessment

Abstract

Objective Anxiety disorders are common among children, but can be difficult to diagnose. An actuarial approach to the diagnosis of anxiety may improve the efficiency and accuracy of the process. The objectives of this study were to determine the clinical utility of the Achenbach CBCL and YSR, two widely used assessment tools, for diagnosing anxiety disorders in youth, and to aid clinicians in incorporating scale scores into an actuarial approach to diagnosis through a clinical vignette. Method Demographically diverse youth, aged 5 to 18 years, were drawn from two samples; one (N=1084) was recruited from a research center, the second (N=651) was recruited from an urban community mental health center. Consensus diagnoses integrated information from semi-structured interview, family history, treatment history, and clinical judgment. Results The CBCL and YSR internalizing problems T scores discriminated cases with any anxiety disorder or with GAD from all other diagnoses in both samples (p values <.0005); the two scales had equivalent discriminative validity (p values > .05 for tests of difference). No other scales, nor any combination of scales, significantly improved on the performance of the Internalizing scale. In the highest risk group, Internalizing scores >69 (CBCL) or >63 (YSR) resulted in a Diagnostic Likelihood Ratio of 1.5; low scores reduced the likelihood of anxiety disorders by a factor of 4. Conclusions Combined with other risk factor information in an actuarial approach to assessment and diagnosis, the CBCL and YSR Internalizing scales provide valuable information about whether or not a youth is likely suffering from an anxiety disorder.

Clinical Decision-Making Following Disasters: Efficient Identification of PTSD Risk in Adolescents

“…Back-to-back histograms investigated the degree of degeneracy across indicators (i.e., high scores on an indicator variable corresponding to no diagnosis ; Van Meter et al, 2014). Areas under the curve (AUC) analyses quantified how well each predictor classified PTSD diagnoses (i.e., sensitivity) and identified cases that did not have PTSD (i.e., specificity).…”

“…Utilizing an assessment framework with optimized screening tools can address front-line psychiatrists', psychologists', and other disaster health workers' need to efficiently triage large groups of patients and establish clear plans of action for each person. Through the use of ROC procedures, improved assessment protocols have been developed for a wide range of pediatric mental health disorders including bipolar disorder (Youngstrom, Freeman, & Jenkins, 2009), mood disorders (Youngstrom, 2014), and anxiety disorders (Elkins, Carpenter, Pincus, & Comer, 2014; Van Meter et al, 2014). Most relevant to the present study, ROC approaches have also been applied to improving assessment protocols for PTSD in community (Suliman, Kaminer, Seedat, & Stein, 2005) and outpatient settings (You, Youngstrom, Feeny, Youngstrom, & Findling, in press), paving the way for more targeted referrals and interventions for individual who suffer from these symptoms.…”

Comparing the Diagnostic Accuracy of Five Instruments for Detecting Posttraumatic Stress Disorder in Youth

“…The YSR-14 scale performed well in the present data at detecting youth PTSD among the contenders compared here, offering a small but significant improvement compared to the YSR Internalizing scores. The Internalizing scale is not specific to PTSD, cutting across anxiety disorders (Ferdinand, 2008; Van Meter et al, 2014) and mood disorders (Ferdinand, 2008; Youngstrom, 2014). When a youth endorses few symptoms on the YSR-14 scale, the likelihood of the youth having PTSD diagnosis is low; and high scores moderately increase the odds.…”

“…According to Evidence Based Medicine (EBM), tests should be combined with other risk factors and clinical findings to revise probability estimates for diagnoses (Straus, Glasziou, Richardson, & Haynes, 2011). Evidence-Based Assessment (EBA) strategies (Youngstrom, 2013) have incorporated these ideas for anxiety disorders (Van Meter, Youngstrom, Youngstrom, Ollendick, & Findling, 2014), attention-deficit/hyperactivity disorder (Frazier & Youngstrom, 2006), and pediatric bipolar disorder (Youngstrom et al, 2004; Youngstrom, Meyers, Youngstrom, Calabrese, & Findling, 2006), among other conditions.…”

“…We hypothesized that the scales would show statistically significant discrimination between cases with versus without PTSD, and that the effect sizes would be medium to large by conventional standards, but moderate for clinical decision-making purposes based on effect sizes seen in prior reports for PTSD (e.g., Gillihan, Aderka, Conklin, Capaldi, & Foa, 2013) as well as using similar scales for anxiety disorders (Van Meter et al, 2014). Additional goals were to compare the diagnostic value of youths’, caregivers’, and teachers’ reports and to examine whether combining multiple informants’ reports would add significant diagnostic information.…”