Psychometric properties of The Clinician Affective Reactivity Index for Assessment of Irritability in a clinical sample of Turkish children and adolescents

First, two child and adolescent psychiatrists who are fluent in both Turkish and English have translated the original scale into Turkish. Second, the researchers studied, restructured, and matched both items from each Turkish form. Third, the Turkish version was then back-translated into English by an independent lecturer in the English Language and Literature Department who was inexperienced with the original CL-ARI (21). The back-translated version compared to the original CL-ARI to confirm the reliability. The latest version of the scale was administered to ten adolescents who were under treatment in the child psychiatry clinic to assess the understandability of items. Authors reviewed and corrected unclear questions.

This translation was compared with the original of the interview by two bilingual child psychiatrists who confirmed the linguistic and content validity of the final version. The study was approved by the Local Ethics Committee of Bursa Uludag University, Faculty of Medicine (Protocol Number: 02.06.2021 / 2021-7/41).

One-hundred-sixteen children and adolescents (11–17 years) were included from the outpatient clinics of the Uludag University Hospital between June 2021 – September 2021. The required sample size has been estimated to multiplying the number of items with 10 times (22). When we considered the 11 items in the CL-ARI, it was planned to include at least 110 youths in the study group. Before starting the study authors also contacted the developer of the scale, Simone P. Haller. The procedure and aim of the study were explained to all participants, and written consent were obtained from all voluntary adolescents and their legal guardians. All participants were evaluated by a child and adolescent psychiatrist using a semi-structured interview, the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Now and Lifetime Form (K-SADS-PL) (23). Diagnostic interviews with children and parents were administered by the principal investigators, two senior child psychiatrists (ST and ŞE) and one research assistant (BEY).

The participants completed the Turkish version of the Affective Reactivity Index (ARI) self-report form, the Revised Child Anxiety and Depression Scale – Child Version (RCADS-C) and Strengths and Difficulties Questionnaire (SDQ) child version. Their parents completed the ARI-parent report form, the Turkish version of the Swanson, Nolan, and Pelham, Version IV Scale-Parent form (SNAP-IV), SDQ-parent form and the Revised Child Anxiety and Depression Scale – Parent Version (RCADS-P).

Inclusion criteria were: i) being diagnosed with any psychiatric disorder as per the K-SADS-PL (23), ii) being aged between 10–18 years, iii) being able to understand and speak Turkish, and iv) giving informed consent to participate in the study. Exclusion criteria involved: i) intellectual disability that hampers the patient’s ability to follow the research instructions in the clinical assessment, ii) history of autism spectrum disorders, iii) serious medical or neurological conditions (i.e., genetic syndrome, epilepsy, cranial tumor, metabolic disease, etc.), iv) head trauma (loss of consciousness or brain surgery), and v) uncooperativeness due to psychiatric symptoms (i.e., agitation, mutism, catatonia, etc.). Children who did not give written consent to the study were not included (n = 6). Similarly, eight adolescents having history of autism spectrum disorders and intellectual disability were excluded from the study. Six adolescents with missing data were also excluded.

The CL-ARI is a semistructured rating scale assessing irritability over the past week by a trained clinician. CL-ARI is conceptualized around three subscales: temper outbursts (range: 0–27), irritable mood between outbursts (range: 0–8) and impairment (range: 0–15). The scorings obtained in the CL-ARI capture the full spectrum of irritability. It consists of two subscales including temper outbursts (six item), irritable mood (two items) and impairment (three items). Additionally, it involves clinical global impression severity, clinical global improvement and overall functioning scores. Items on temper outbursts and irritable mood subscales encompasses the frequency, duration, and severity of symptoms. Clinical Global Impressions Scale for Disruptive Mood Dysregulation (CGIS-DMDD) is rated based on the clinicians’ overall judgment. The reliability (Cronbach’s α=0.89) and validity of the CL-ARI in children has been previously reported (21).

The temper outbursts subscale assesses the frequency (scored on a 5-point scale between “0=none” and “4=more than one outburst every day”) and duration (scored on a 6-point scale between “0=none” and “5=60 min”) of temper outbursts. The second subscale assesses the irritable mood which evaluates the frequency (scored on a 4-point scale between “0=none” and “3=four or more days”), duration (only implemented if the irritable mood frequency rating is rated at the maximum level which is “3=four or more days”), and severity (scored on a 6-point scale between “0=not present” and “5=severe”) of irritable mood. The third subscale assesses impairment in three different settings (i.e., family, school and peers) on a 6-point scale (between “0=none” and “5=severe”). Separate interviews are conducted with the parents and children. Clinicians synthesize the data to reach a consensus rating. Three subscales contribute equally to the total score based on the recommended formula below (21).

The Affective Reactivity Index (ARI) is a scale developed for the evaluation and monitoring of irritability. It has both a parent form and a self-report form for children and adolescents. Stringaris and colleagues created it as a dimensional measure of irritability (19). Evaluating the symptoms of irritability for the last six months, this questionnaire involves six symptom items and the seventh item assesses the impairment in functioning. Ratings are given based on a three-point scale (i.e., “0=not true”, “1=sometimes true”, “2=definitely true”). The reliability and validity of the ARI in typically-developing children has been reported (19, 24). The Turkish validity and reliability study was carried out by Kocael and colleagues (25). The total ARI score ranges from 0 to 12 as the sum of the first six items.

The K-SADS-PL was originally developed by Kaufman et al. (1997) to evaluate psychiatric disorders of children and adolescents (26). The KSADS-PL has been updated to be compatible with DSM-5 diagnoses, and the recent version of KSADS-PL was also translated into and validated in the Turkish language (23).

Another scale used to screen for mental problems in children and young people is the SDQ, developed by Robert Goodman in 1997 (27). The questionnaire is currently translated into more than 40 different languages. This questionnaire has a parent and school form for the ages of 4–16, and an adolescent form for the ages 11–16 that the adolescent himself fills. The adolescent form contains the same items as the parent form. The scale was filled in as self-report. SDQ includes 25 questions, some of which question positive and some negative behavioral characteristics. These questions are grouped under five sub-titles; (1) behavioral problems, (2) attention deficit and hyperactivity, (3) emotional problems, (4) peer problems, (5) social behaviors. As each title is evaluated within itself, the sum of the first four titles gives the total difficulty score (28). Validity and reliability assessment of both parent and adolescent forms in our country was performed by Güvenir and colleagues (29).

The RCADS parent and child form is a 47-item questionnaire designed to evaluate depression and anxiety disorders in children and adolescents according to DSM-IV diagnostic criteria. Response options are based on four-point Likert-type scales (0=never, 1=sometimes, 2=often, and 3=always). Both versions include six subscales (separation anxiety disorder, social phobia, obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, major depressive disorder), as well as a total anxiety score (sum of five anxiety subscales) and total anxiety and depression (internalizing disorder) score (the sum of all six subscales) (30). The Turkish validity and reliability study of the parent and child form of RCADS was performed by Görmez and colleagues (31, 32).

This scale, which was developed according to DSMIV criteria, consists of nine items questioning attention deficit, six items questioning hyperactivity, and three items questioning impulsivity (33). A Turkish validity study has not yet been published, but it is available in Turkey in large-scale sample studies (34). The mean threshold value of 1.5 SD for each item is similar to that in American community-based studies (33, 34).

The study sample consisted of 116 youth with psychiatric disorder (14.1 ± 2.1 years, 59.5% female). Most of the patients had no family history of psychiatric disorder (n = 93, 81.1%). The most common diagnoses were major depressive disorder (n = 39, 33.6%), attention deficit/hyperactivity disorder (n = 34, 29.3%), obsessive-compulsive disorder (n = 33, 28.4%) and generalized anxiety disorder (n = 31, 26.7%). Details of the demographic, illness and treatment characteristics of patients are depicted in Table 1.

Cronbach’s alpha values were 0.919 for the CL-ARI total score, 0.842 for the temper outbursts, 0.861 for the irritable mood, and 0.840 for the impairment subscales. Intraclass correlation coefficients of interrater reliability were high for the temper outbursts (r = 0.993), the irritable mood (r = 0.993), the impairment (r = 0.917), and the total score (r = 0.991). Item - total score correlation coefficients were between 0.560–0.829 (Table S1).

A two-factor PCA model with direct oblimin rotation explains 66.5% of total variance (Table 2). Kaiser-Meyer-Olkin measure was 0.848 and Barlett’s test of sphericity was significant at < 0.001 level. Temper outbursts – mild duration (item 2), temper outbursts – moderate frequency (item 3), temper outbursts – severe frequency (item 5), temper outbursts – severe duration (item 6), impairment – school (item 10) and impairment – peers (item 11) were grouped together under factor 1, while temper outbursts – mild frequency (item 1), temper outbursts – moderate duration (item 4), irritable mood frequency (item 7), irritable mood severity (item 8) and impairment – family (item 9) fell under factor 2.

In the sample, there was a high level of correlation between the self-report ARI-child/parent forms and the CL-ARI total and subscale scores, and a moderate-high level of correlation between the behavioral SDQ child and parent forms and the CL-ARI total and subscale scores (Table 3). Correlations with measures of other dimensions of psychopathology (symptoms of anxiety, depression, attention and hyperactivity problems) were not significant.

To evaluate the discriminant validity of the CL-ARI further, the total scores and subscale scores of the CL-ARI were compared between patients with CGIS-DMDD ≥ 3 (at least mild irritability) and those with CGIS-DMDD < 3 (borderline or no irritability) using the Student’s t-test (Table 4). All CL-ARI scores significantly differed between both groups with large effect sizes.

In the ROC analysis of the capacity of the CL-ARI to demonstrate the differentiation between clinically significant (CGI-S ≥ 3) irritability, the area under the ROC curve was 0.800 for the all patients (Figure 1). The optimal cut-of values was found as ≥ 17.45% for the weighted total score (sensitivity=75% and specificity=75%).

FIGURE 1