Validation of the Diagnostic Infant and Preschool Assessment in a Danish, trauma-exposed sample of young children

A total of 62 caregivers were interviewed about their child. Inclusion criteria included caregivers of Danish children aged 1-6 years and child exposure to at least one potentially traumatic event. Caregivers who had insufficient Danish language capabilities to participate in the interview or severe cognitive functional impairments could not participate in the study. The children themselves did not participate in the study because the study only included caregiver-report measures. Caregivers were recruited from five mental health clinics for children (n= 19) and two women’s shelters located in the Capital Region and the Southern Region of Denmark (n= 3). Furthermore, caregivers were recruited from the Danish Southern Regional Children Center who does psychological assessments of children in cases of suspected physical or sexual abuse against a child (n= 33). Lastly, caregivers were recruited from a national network for women victimized by intimate partner stalking (n= 7).

Caregivers received written and oral information about the study and gave oral consent if they wished to participate. Thereafter, time and date for the interview were scheduled in person or over the telephone. Caregivers of 65 children consented to participate. Three caregivers did not participate in the interview because they did not show up for the planned interview or were unreachable by phone and e-mail.

The study was a cross-sectional assessment study. Interviews were conducted between March 2014 and November 2017. The measures were administered by two psychologists from the Danish National Center for Psychotraumatology, five clinical psychologists from the Children Center and six graduate psychology students. Prior to their first interview, all psychologists and students conducting the interviews received training in administration and scoring of the DIPA and administration of the SDQ. After the interviews, psychologists and students received supervision in how to score the DIPA: All psychologists and students made notes on their interviews, and the scoring of the interviews were reviewed with one of the two psychologists from the Danish National Center for Psychotraumatology.

Interviews were conducted in person by default; however, as a safety precaution the parents from the network for victims of stalking were given the option to have the interview done by phone if they were currently hiding. All seven parents victimized by stalking were interviewed over the phone. The administration time for the DIPA in the present study was between one and two and a half hour depending on the number of symptoms the child displayed. Feedback was offered on the results of the interview. For caregivers recruited from a mental health facility the results of the DIPA could supplement the ongoing assessment of their child. The caregivers recruited from the network for victims of stalking were offered a written feedback. The study was approved by the Regional Scientific Ethical Committees for Southern Denmark (S-20150009).

DIPAis a semi-structured interview of caregivers about their child aged from 1 to 6 years. The DIPA assess symptoms of 13 disorders: PTSD, MDD, bipolar affective disorder (BAD), ADHD, ODD, CD, SAD, specific phobia, social phobia, GAD, OCD, RAD, and sleep disorder based on the DSM revised version IV (42) and the RDC-PA (14). The DIPA includes a list of 11 different types of traumas and a 12^thcategory of “other traumas”. The interviewer goes through the list with the caregiver before symptoms of PTSD are assessed. The clinical psychologists and students incorporated the DIPA into their established clinical assessment time slot, therefore due to a limit in available time, eight of the 13 disorders (PTSD, MDD, ADHD, ODD, CD, SAD, RAD, and sleep disorder) were included in the present study.

For each of the disorders every symptom question begins with a stem question which fits each symptom of the DSM-IV specific disorder. A simple yes or no response from the caregiver of whether the symptom is present is never accepted as sufficient. The interviewer is instructed to get an example of every symptom to verify or disprove the respondent’s answer with real examples. After each stem question and example, the interviewer judges whether follow-up probes are needed, to assess whether the description is that of typical child behavior displayed in the child’s age group or whether the behavior is symptomatic of the disorder in question. The DIPA questions are worded explicit to query about a symptom by framing behaviors as “problem” behaviors, “excessive” behavior, “often”, “too much”, things that children “have trouble with”, and if the child shows a certain behavior “more than the average child his/her age”. This way the interviewer and caregiver have a common frame of reference for developmental differences within and beyond the preschool period. If a symptom is not present, a score of 0 is given. If the symptom is present, a score of 1 is given.

Following each disorder, functional impairment is assessed if the child shows symptoms of the disorder. Five items query about role functioning, parental relationships, sibling relationships, day care provider/teacher relationships, relationships with peers, and in public, and one item assesses child distress (except for ADHD and ODD). Following the procedure of Scheeringa and Haslett (1), functional impairment was analyzed without child distress. Continuous variables of functional impairment included the sum of all five items. Categorical presence of functional impairment for fulfillment of diagnostic criteria was accounted for if at least one of the five items was endorsed.

For this study, fulfillment of diagnostic criteria for the disorders of PTSD, ADHD, ODD, CD, SAD, and RAD (without the pathogenic care criterion) were calculated based on DSM-IV-TR algorithms (42). Disorders of PTSD, ADHD, ODD, CD, and SAD were also calculated based on the WHO’sInternational Statistical Classification of Diseases and Related Health Problems, 10th revision(ICD-10) algorithms. Furthermore, PTSD-AA, MDD, RAD, and sleep disorder (sleep onset dyssomnia or night waking dyssomnia) were also calculated according to the RDC-PA (14). For the PTSD-AA, only one of the seven symptoms in Criterion C (avoidance and numbing symptoms) is required (4). For the developmentally modified MDD, symptoms of sad mood and diminished interest in significant activities have to be present at least eight days out of two continuous weeks (43). The alternative criteria for RAD inhibited subtype endorse three out of four symptoms of not seeking comfort when distressed, not responding to comfort, limited positive affect or excessive levels of irritability, sadness or fear or reduced social and emotional reciprocity. Alternative criteria for RAD disinhibited subtype include endorsing two out of three symptoms of overly familiar behavior around unfamiliar adults, rarely checking back with caregiver when venturing away or willingness to go off with an unfamiliar adult. Sleep disorder was present when one symptom in the DIPA of either sleep onset dyssomnia or night waking dyssomnia was endorsed (44).

The DIPA was forward translated by a research group at the Danish National Center for Psychotraumatology; one psychologist and researcher translated the DIPA into Danish and four colleagues revised the Danish wording. Subsequently, content validity of the Danish version was evaluated in a pilot study by a group of clinical psychologists from mental health clinics in Odense and further adaptations were made. The DIPA (41) was translated back into English by the research group and approved by Michael S. Scheeringa.

SDQ(31) is a brief behavioral screening questionnaire. The SDQ contains 25 items about the child’s symptoms and strengths which are scored on a three-point Likert scale (0 = “not true”, 1 = “somewhat true”, and 2 = “certainly true”). The items are divided between five subscales: the hyperactivity scale, the emotional symptoms scale, the conduct problem scale, the peer problem scale, and the prosocial scale. The first four scales are summed up into the Total Difficulties scale with a score ranging 0-40. The five items on the prosocial scale are worded positively and are scored 2 for “not true” and 0 for “true”. In this study the parent-report extended version was used with additional items assessing chronicity and impact of the difficulties on distress, home, friendships, learning, leisure activities, and burden on others (32) which are scored on a four-point Likert scale (0 = “not at all”, 1 = “only a little”, 3 = “quite a lot”, and 4 = “a great deal”). The impact supplement is calculated by recoding and summing up the impact on distress, home, friends, learning, and leisure activities. The SDQ has been validated with Danish children and has good psychometric properties (33-35).

Caregivers of 62 children participated in the study. In total, 55 (88.7%) caregivers were parents, six (9.7%) were foster parents, and one caregiver (1.6%) was another primary caretaker of a child who lived at a children’s home. Table1displays sample characteristics of the children grouped by recruitment facility and for the total sample. The children whose caregivers were recruited from women’s shelters and from the network for victims of intimate partner stalking were grouped together because the children from both places had all witnessed varying types of intimate partner violence. The children’s ages ranged between 1 year and 6 months and 6 years and 11 months. Age deviated significantly from normal, with skewness of −0.52 (SE = 0.30) and kurtosis of −0.62 (SE = 0.60). Seven children (11.3%) were between 1 year and 6 months and 2 years and 11 months, 21 children (33.9%) were between 3 years and 4 years and 11 months, and 34 (54.8%) children were between 5 years and 6 years and 11 months old. All the children had been exposed to at least one trauma (range 1-8, Mdn = 3) as assessed with the DIPA. Total number of traumas was non-normally distributed, with skewness of 0.94 (SE = 0.30) and kurtosis of 1.50 (SE = 0.60). Most of the children had experienced several traumas with 80.7% (n= 50) exposed to two or more traumas. Moreover, 30.7% (n= 19) of the children had experienced four or more traumas. Table2shows how many children had experienced the different types of traumas based on the twelve categories of trauma listed in the DIPA. The most common traumas reported were hospitalization which 59.7% (n= 37) of the children had experienced and witnessing violence which 51.6% (n= 32) had experienced. None of the children had experienced a natural disaster. Moreover, for 79% of the children (n= 49) caregivers reported other traumas or distressing experiences not described by the categories. These included stalking, psychological violence, neglect, placing in foster care or other acute separation from primary caregiver, parental mental disorder, and severely problematic divorce.

The aim of the present study was to examine the internal reliability and convergent validity of the Danish version of the DIPA using a sample of caregivers of young Danish children exposed to psychological trauma. The study is to our knowledge the first study to examine the reliability and validity of DIPA in a European context. The DIPA showed good to excellent internal reliability for six out of the eight investigated scales (MDD, ADHD, ODD, and SAD and for the overall scales of RAD and PTSD) and acceptable internal reliability of CD and RAD disinhibited subtype. Internal reliability was adequate for the scale of sleep disorder and for the subscales of PTSD re-experience and hyperarousal.

The DIPA evidenced acceptable convergence with the SDQ Total Difficulties scale and subscales. The association between DIPA PTSD and the SDQ emotional subscale was large. When PTSD was regressed on the SDQ emotional subscale, other disorders than PTSD did not affect the relationship between the total PTSD score and the SDQ emotional subscale. However, when the total PTSD score was regressed on the SDQ Total Difficulties scale and other disorders than PTSD was added to the model, the correlation between PTSD and the SDQ Total Difficulties scale was no longer significant. Instead, the number of other disorders was a significant predictor of the SDQ Total Difficulties scale, suggesting that these disorders better explained the score on the Total Difficulties scale than the PTSD score. Furthermore, large associations were found when the DIPA scales of ADHD, ODD, CD, and SAD were matched to the relevant SDQ subscales of hyperactivity, conduct problems, and emotional symptoms. In addition, functional impairment of the DIPA PTSD symptoms showed adequate association with the impact supplement of the SDQ. These findings add to the results of Scheeringa and Haslett (1), and especially the scales of disorders of ADHD, ODD, and SAD seem to function well.

In the present study, correlations of scales of MDD and PTSD were better than those of Scheeringa and Haslett (1) when MDD and PTSD were compared to the SDQ Total Difficulties scale and the emotional symptoms scale. This may be due to use of different comparison measures and subscales and differences in study samples. However, differences in results for the scale of PTSD may also reflect the challenges of investigating validity of PTSD measures for young children as no other golden standard of PTSD measure for preschool children exists. Therefore, in this study we investigated convergent validity of the DIPA and compared the DIPA to a broad and well-validated measure, the SDQ, even though the SDQ does not include a subscale for PTSD, and we used a sample of highly trauma-exposed young children. Future examination of the DIPA PTSD measure would benefit from a closer match with another well-functioning PTSD measure for this age group to examine concurrent criterion validity of DIPA PTSD module. Still, this study provides initial evidence for the validity of the Danish version of the DIPA for trauma-exposed young children for use in research and in clinical practice where early identification of children with trauma symptomatology is imperative. The DIPA provides researchers and clinicians with a thorough and detailed semi-structured interview that covers developmentally sensitive questions about both behavioral, observable markers of preschool child symptomatology and internalized symptoms as well as impact of symptoms on child functioning. As a standardized measure with specific details and follow-up probes that educate and clarify answers of the caregiver to get reliable answers, the DIPA works around some of the challenges of assessing very young children that may have limited abilities to talk about trauma-exposure and symptoms.

Furthermore, the study reported on child psychopathology, as assessed with the DIPA, according to the diagnostic criteria of the DSM-IV, ICD-10, and the developmentally sensitive RDC-PA. As demonstrated in other studies (4,6), more children were identified as suffering from PTSD according to the RDC-PA than the DSM-IV (48.4% compared to 14.5%). The alternative algorithm for PTSD has been shown to be more developmentally sensitive for preschool-aged children (5,6), and thus seems to improve the possibility of identifying children with substantial posttraumatic stress symptoms and impairment who are in need of treatment.

The present study is, however, not without its limitations. First, the study includes a relative small sample with participants recruited from several clinics and network. In Denmark, children exposed to traumatic events are often spread out on different institutional facilities and mental health clinics assessing and treating children with a variety of emotional and behavioral difficulties. The possibilities for intervention for traumatized children vary depending on the geographical region and the type of trauma that the child has experienced. Therefore, conducting an assessment study of preschool children which focused on trauma symptomatology proved difficult despite substantial recruitment efforts. However, the present study still includes a sample similar in size to those of other validity studies on measures of child trauma symptomatology (e.g. 1, 46). Furthermore, the present study demonstrated that a great part of the children, according to the results of the DIPA, exhibited trauma symptomatology. This highlights the need for an increased focus on trauma exposure and trauma symptomatology in clinical assessment of preschool children. Another limitation of the study includes the fact that a large part of the children had been exposed to physical violence despite the inclusion of different types of traumas. Moreover, the sample comprised children recruited from clinics as well as children recruited through women’s shelters and a network of stalking victimized parents. Future validity studies on the DIPA would benefit from including other types of clinical samples and samples from child psychiatry with a diverse range of trauma exposure. Moreover, due to time constraints in clinical practice, only scales for eight out of 13 disorders were included in the present study. Scales of all disorders should of course be validated in future studies and matched well with other measures of each specific disorder when available measures exist. Furthermore, a more thorough examination of the reliability of the DIPA is needed. The present study is to our knowledge the first validity study to examine internal consistency of the scales of the DIPA. However, the study is limited by not examining inter-rater reliability, nor test-retest reliability. Moreover, the study did not include a control group of non-symptomatic children. Future studies should include a comparison of children with trauma symptomatology and healthy children to examine whether the DIPA is able to differentiate between symptomatic children and healthy children in this young age group. Lastly, the Danish version of the DIPA would benefit from being adapted to match symptoms of disorders of DSM-5, as the American version has been, but also to the ICD-11. As for now, the current Danish version of the DIPA adheres to disorders of both DSM-IV, ICD-10 and RDC-PA.

The present study is the first to provide evidence to support the validity of the Danish version of the DIPA. The DIPA is a developmentally sensitive, detailed diagnostic caregiver interview for children aged 1-6 years. The DIPA covers symptoms of 13 different diagnoses and functional impairment for the child for each disorder in self-contained modules. Thereby, the entire interview can be used to obtain a thorough and broad assessment of child symptomatology or individual modules can be used when time issues are present. Moreover, the DIPA includes a trauma screening covering 11 different types of trauma and functional impairment of symptoms for the child and its closest relations. Using the DIPA can help in securing early and confident assessment of preschool children exposed to trauma and allocation of appropriate support and treatment for the child and family.