When the rater uses only one part of a rating scale he is most likely committing what kind of error?

V.B. Behavioral Rating Scales and Behavioral Checklists

A behavioral rating scale is an assessment instrument completed by a clinician or a third party (e.g., significant other, teacher, parent, peer) that includes items that assess one or more targeted client behaviors. A behavioral checklist is similar to a behavioral rating scale but often includes fewer items and may include dichotomously scored response options. Many behavior rating scales and behavioral checklists have been standardized using a normative sample of individuals and aggregate raw data into standardized scale scores or global scores.

Behavioral rating scales are frequently divided into two classifications: narrow band behavior rating scales and broad band behavior rating scales. Narrow band behavior rating scales include items that sample from a small number of domains and are not intended to be global measures of an individual's behavior. Broad band behavior rating scales usually include more items, sample from a wider spectrum of behaviors, and are often used to screen for more than one disorder or behavioral syndrome.

For example, behavioral checklists and behavioral rating scales are the most popular methods of gathering information in assessing ADHD. Narrow band measures include the 55-item Social Skills Rating System, which divides item content into three narrow domains: problem behaviors, social skills, and academic competence. Another narrow band instrument is the Disruptive Behavior Rating Scale (DRS). The DRS includes item content covering oppositional defiant disorder, ADHD, and conduct disorder. Broad band behavioral rating scales include the Child Behavior Checklist (CBCL) and the Conners Parent and Teacher Rating Scales. Both the CBCL and the Conners Scales provide several scale scores and include versions for parents, teachers, and youths to complete. The popularity of these behavioral assessment methods can be attributed to their cost-efficiency, ability to quantify the opinions of important persons in a client's life, and their ease of administration. In addition, the most widely used instruments (e.g., the CBCL) rest on an extensive foundation of empirical literature that testifies to their reliability and validity.

Although behavioral rating scales and behavioral questionnaires are popular, it should be emphasized that they are indirect measures of behavior. As indirect measures, data collected using behavioral rating scales and behavioral checklists reflect a rater's retrospective impression of a client's behavior rather than an objective recording of the rate at which behavior occurs, as with naturalistic behavioral observation methods. Consequently, all behavioral rating scales and behavioral checklists are subject to rater bias regardless of the rigor with which the instrument is designed. Although indirect observation of behavior can be useful in behavioral assessment, its limitations need to be understood by the behavioral assessor.

In addition to being indirect measures of behavior, behavior rating scales and behavioral checklists rarely provide information pertaining to the functional relations of variables. Most behavior rating scales and behavioral checklists include items that measure topographical behavioral dimensions rather than functional relations. To some degree, the contextual variability of behavior can be addressed by having multiple informants complete the instrument provided each informant observes the client in different contexts (e.g., having a parent and a teacher complete the same rating scale). A thorough functional assessment, however, requires greater attention be paid to other variables that may be maintaining the behavior (e.g., the type of reinforcement received for an oppositional behavior; whether the problem behavior results in avoidance of an aversive event or situation).

Assessment Procedures

The assessment of psychosis, as well as other neuropsychiatric symptoms, in dementia requires gathering detailed information regarding circumstances, timing, frequency, setting, and severity of symptoms. Identifying the antecedents to psychotic symptoms, (e.g., being in an unfamiliar environment) and their timing (e.g., whether symptoms occur at night) can lead to preventative measures. For instance, changes in the home environment, such as a new visitor, may induce misidentification syndromes. Other antecedents may include physiological states, such as hunger, fatigue, or pain, which may either introduce new symptoms or amplify the intensity of existing psychotic symptoms.

Assessing caregiver's response to psychotic symptoms can also be helpful in determining more adaptive responses. For instance, some caregivers engage in lengthy arguments with the patient trying to convince the patient that they are misperceiving reality—these arguments often leave the caregiver exasperated and do little to change the patient's views. Indeed, assessing the emotional expressivity variable for caregivers of those with dementia may yield high therapeutic value, especially in planning interventions for those care recipients exhibiting psychotic symptoms (Adams, 1997). Alternative strategies, such as distraction, may reduce caregiver burden. Assessing the severity of psychosis can help to identify whether symptoms are dangerous and require immediate pharmacological management, or, if not, whether they can be dealt with through distraction or other behavioral strategies.

There is good reason to conduct a careful behavioral assessment in order to guide non-pharmacological strategies—the pharmacological management of behavioral disturbances, including psychosis, in AD has been the subject of much recent discussion. There are potential risks of antipsychotic medications (e.g., the FDA black box warning regarding increased risk of mortality in AD patients who are placed on antipsychotics), and the findings of the recent Multi-center Clinical Antipsychotic Trials of Intervention Effectiveness study indicate that benefits of antipsychotic medications in reducing neuropsychiatric symptoms were questionable (Schneider et al., 2006). As the pharmacologic treatment of psychosis in AD is still evolving, behavioral and family approaches become all the more important.

There are a number of clinician and caregiver rated scales for measuring the neuropsychiatric symptoms of dementia. These scales include questions on psychosis embedded in subscales measuring other neuropsychiatric syndromes.

The Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) is a psychometrically validated assessment that assesses the nature and severity of behavioral pathology. BEHAVE-AD consists of a 25-item scale with seven categories: paranoid and delusional ideation; hallucinations; activity disturbances; aggressiveness; diurnal rhythm disturbances; affective disturbances; and anxieties and phobias. Each category is scored on a 4-point scale where 0 = not present, 1 = present, 2 = present with an emotional component, 3 = present with an emotional and physical component. There is also a 4-point global assessment scale of caregiver distress and/or perceived danger to the patient. This assessment reliably measures behavioral disturbances independent of cognitive deficiencies, allowing for more appropriate treatment of behavioral symptoms (Reisberg et al., 1987).

The Caregiver-Administered Neuropsychiatric Inventory (CGA-NPI) determines the presence, frequency, and severity of neuropsychiatric symptoms. The CGA-NPI yields 12 domain scores (corresponding to 12 psychiatric symptoms), as well as a total score, each reflecting the product of frequency and severity of symptoms. Although not part of a formal CGA-NPI domain scores or total, each of the 12 domain sections in the CGA-NPI includes a question in which the caregiver rated, on a scale of 0 (not at all) to 5 (very severely or extremely), the level of emotional distress (to the caregiver) from the patient's neuropsychiatric symptoms in that domain (Kang et al., 2004).

The Behavioral Rating Scale for Dementia (BRSD) is a standardized instrument that rates the frequency and severity of a wide range of psychopathology in patients with probable Alzheimer's disease. There are 51 items, 48 of which are related to specific signs and symptoms, and three are open-ended questions about general psychopathological disturbances. Each of the items is rated by frequency of occurrence. The examiner rates each symptom according to anchored scoring guidelines, and the assessment is administered to caregivers (Tariot et al., 1995).

Case Study 2

Ms G, a 78-year-old female, was referred to an Outpatient Geriatric Psychiatry Clinic by her family care practitioner for a psychiatric evaluation and treatment recommendations. History revealed that the patient was diagnosed with mild Alzheimer's disease when she was 75-years-old by a neurologist at the Alzheimer's Disease Research Center. Among other neuropsychological test scores indicating cognitive decline, Ms G had a score of 121 on the Mattis Dementia Rating Scale (DRS). Around that time, the patient and her family noticed increasing memory problems; she would frequently forget phone messages, family visits, and where she put her belongings. Although Ms G was not able to do her own finances, she was able to independently manage other instrumental activities of daily living, like cooking and doing her own laundry; with assistance, Ms G continued to live alone for two years. However, when Ms G exhibited some potentially dangerous behaviors (leaving the stove on and letting the bathtub overflow), the family arranged for her to move in with her daughter's family.

After the move, Ms G began to exhibit delusions, peaking within two months. She had been accusing her daughter, with whom she lived, of stealing money from her bank accounts. Ms G also held the belief that she only had one granddaughter, and this granddaughter would change identities to disguise herself and steal Ms G's personal belongings out of her room (the Fregoli delusion). Some items Ms G claimed were stolen never existed.

The patient was seen at the Outpatient Geriatric Psychiatry Clinic for evaluation. A medical evaluation, including a blood test, urine sample, physical exam, and a CT scan were completed. Ms G was generally healthy, although she had non-insulin dependent diabetes. These evaluations did not indicate any underlying medical condition that might have contributed to the onset of the patient's psychotic symptoms. An extensive medical and family history was collected from all available sources, i.e., medical records and family members. Ms G had no previous psychiatric history. The patient also underwent a follow-up neuropsychological screening and was administered the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD). A repeat DRS score of 110 indicated further decline since the patient's initial diagnosis three years prior. The BEHAVE-AD revealed elevations on symptom clusters representing delusions and agitation, but not on hallucinations or other behavior problems.

Evaluation of the context of delusional statements revealed that they seemed to occur during evenings when the entire family was home. Ms G exhibited no potentially dangerous behaviors associated with the delusions (e.g., aggressiveness), however they were extremely distressing for the patient's family. Her granddaughters went to great lengths to try to prove to Ms G that she was not being stolen from, during which Ms G would often become agitated and tearful. Ms G was sometimes agitated and would wander around the house, sometimes late at night. It was apparent that she was having a hard time adjusting to living in a new environment and with other people.

Based on the evaluation, Ms G’s symptoms were judged to be consistent with psychotic symptoms associated with Alzheimer's disease, and also consistent with progression to the middle stages of AD. No medical problems or psychotic disorder were suspected. Moreover, antecedent to the patient's psychosis was moving to a new house where other people lived. Weighing treatment options with Ms G’s family led to an agreement to observe Ms G over the period of one month to see if assimilation to the new environment might improve her symptoms. To accelerate this adjustment, steps were taken which included putting familiar objects in Ms G's room that would remind her of her old home. Family members were advised to redirect the patient rather than confront her accusations. Additionally, the family was referred to a support group at the Alzheimer's Disease Research Center. If following these recommendations did not result in substantial benefit within one month, the plan was to prescribe a low dose of antipsychotic medication.

Fortunately, at a follow-up appointment one month after being seen at the Outpatient Geriatric Psychiatry Clinic, it was determined that Ms G's delusions had abated somewhat. Ms G continued to express delusional beliefs about being stolen from, but these were less frequent, and the family was less distressed about them. Repeat BEHAVE-AD scores revealed slight declines in symptom severity. The family was advised to follow up with the clinic if there was a worsening of symptoms.

Psychopathology Categorization Method

A common view of the role of pediatricians in behavioral matters is that they should screen for behavioral disturbances, as they do for developmental delay and various physical problems, so that they can refer troubled children to mental health specialists who are more proficient with these issues (Costello, 1986; Jellinek et al, 1986). A dozen or more of these screening checklists are available—brief checklists (<10 minutes), longer ones, and ones designed for special areas of function. Detailed analyses of their characteristics can be found periodically in various reviews in the Journal of the American Academy of Child and Adolescent Psychiatry and in Pediatrics in Review (Glascoe, 2000; Perrin and Stancin, 2002).

Among the best known of the brief checklists are the Pediatric Symptom Checklist (Jellinek et al, 1986), Eyberg Child Behavior Inventory (Eyberg and Ross, 1978), Conners Parent Rating Scale (Goyette et al, 1978), and Parents' Evaluations of Developmental Status (PEDS) (1997). Some screening scales requiring more time include the Child Behavior Checklist (Achenbach and Edelbrock, 1983), Behavior Assessment System for Children (BASC) (Reynolds and Kamphaus, 1992), Brief Infant-Toddler Social and Emotional Scale (BITSEA) (Briggs-Gowen et al, 2004), Ages and Stages Questionnaire: Social Emotional (ASQ:SE) (Squires et al, 2002), Devereux Early Childhood Assessment Program (DECA) (LeBuffe and Naglieri, 1999), and Vineland Socio-Emotional Early Childhood Scale (Sparrow et al, 1998).

Some additional scales are designed to evaluate specific areas of function, such as coping, self-esteem, or social skills or of malfunction, such as depression, inattention, or autism. The reader is directed to specific chapters addressing these matters for more extensive information. The question of the accuracy and ethics of screening all teenagers with a brief questionnaire to discover early signs of depression is discussed elsewhere.

The proposed advantages of these behavioral rating scales are as follows:

They gather information from the informants with the greatest experience with the child.

They include some behavior not likely to be observed by the clinician, such as sleep.

They are inexpensive and efficient.

Some available normative data allow determinations of deviations.

They provide quantitative assessments concerning qualitative aspects of behavior.

Perhaps the most important use of such a screening scale by a pediatrician may be to facilitate communication between the physician and the parent or teacher, in that it indicates the physician's concern for behavioral issues and promotes discussion of them. Despite their value in psychiatric research and practice, however, these questionnaires all have significant problems that interfere with their use in pediatric primary care, as follows:

The data produced are of little assistance in the identification and management of the common behavioral concerns parents bring to pediatricians, such as sibling quarrels and resistance to toilet training. Screening and referral for major behavioral problems is only a small part of the appropriate mental health role of the pediatrician.

Although various claims are made of their psychometric qualifications, no proof has been offered that these questionnaires detect important abnormalities any better than do a few appropriately phrased and directed interview questions, or that they result in an improvement in physician performance (Stancin and Palermo, 1997). The true efficiency of these scales in pediatric practice remains to be shown.

With rare exceptions, the available scales rate only abnormalities and do not evaluate positive evidence of behavioral adjustment, such as social competence or self-esteem. The few questionnaires that evaluate positive aspects include the Strengths and Difficulties Questionnaire (Goodman, 2001) and Behavior and Emotional Rating Scale (BERS) (Epstein and Sharma, 1998).

They are highly impressionistic. An item such as “talks too much” measures the caregiver's judgment of what constitutes an excess of talking as much as it does the actual quantity of the behavior in the child. The parents are exercising the diagnostic judgment that should be made by the clinician.

They usually give equal weight to ratings of problems of unequal significance, such as nose picking and fire setting.

They typically ask about the overall frequency of the behavior without regard for its varying significance in different settings, such as whether trouble paying attention is a problem with listening to safety rules or learning irregular verbs as well as with video games.

The context and the parent-child interaction are typically neglected. Two exceptions are the Child and Adolescent Psychiatric Assessment (CAPA) (Wamboldt et al, 2001) and Keys to Interactive Parenting Scale (Comfort et al, 2006). Because pediatric counseling is likely to deal with the parent-child interaction, any diagnostic system failing to uncover that would be of limited value.

Critics in the mental health professions have complained that pediatricians are not doing a good job in this screening process and are failing to detect substantial numbers of problems present. These conclusions may be correct to some extent, but they say little about the types and significance of problems being missed or the consequences of delay in detection. A more appropriate analysis of this situation (Horowitz et al, 1992) showed “when using a classification system developed specifically for primary care settings, clinicians do identify a large number of children (with) psychosocial and developmental problems.” Appropriately directed interviewing has been shown to produce a higher yield of the existing problems (Wissow et al, 1994).

Neuropsychological Outcomes of Subthalamic Nucleus and Global Pallidus Deep Brain Stimulation for Parkinson’s Disease

Generally, studies using neuropsychological instruments and behavioral rating scales report higher rates of cognitive decline after DBS than do studies relying on patient/clinician report. There are now many studies examining neurobehavioral outcomes after DBS and thus it becomes instructive to review recent meta-analyses of findings The properties and characteristics of recent meta-analyses are presented in Table 10.2, and effect sizes concerning outcomes either in cognitive and behavioral domains or on specific neuropsychological tests are presented in Tables 10.3 and 10.4, respectively. It is emphasized that while meta-analyses are useful in detecting treatment effects when the effects are small or when studies yield inconsistent findings and have small samples, their value is determined by the quality of studies included in the analysis. The tables also reveal that the majority of effect sizes refer to patient groups' changes relative to their own preoperative baseline, some meta-analyses combine outcomes from different surgical targets or uni- and bilateral interventions and some report effect sizes relative to change in the DBS group compared to a control group or DBS of another target.

Table 10.2. Properties and Characteristics of Meta-Analyses of the Neuropsychological Effects of Deep Brain Stimulation

GPi, Globus pallidus internus; RCT, randomized controlled trial; SMD, standardized mean difference (effect size); STN, subthalamic nucleus.

Source: From Tröster (2017).

Table 10.3. Standardized or Weighted Mean Differences (Effect Sizes) Reported by Meta-Analyses of Effects of Deep Brain Stimulation on Cognition and Emotion Domains and Quality of Life

Source: From Tröster (2017).

Table 10.4. Standardized or Weighted Mean Differences (Effect Sizes) Reported by Meta-Analyses of Effects of Deep Brain Stimulation on Specific Neuropsychological Tests

Source: From Tröster (2017).

The data presented in Tables 10.3 and 10.4 reveal that effect sizes associated with changes within cognitive domains or on specific tests are usually small (occasionally moderate) after both GPi and STN DBS. The most consistent and largest effect sizes (pre- to postoperative change) are reported for verbal fluency (semantic marginally greater than phonemic). This finding is consistent with prior reports that mild to moderate verbal fluency reductions occur in 25%–50% of persons after bilateral DBS (Fields & Tröster, 2000; Funkiewiez et al., 2004). Clinically it is worth noting that the fluency changes usually persist and, probably due to the natural course of the disease, might even worsen between 5 and 8 years after surgery (Fasano et al., 2010). Importantly, the immediate postoperative verbal fluency decrements appear not to foretell more rapid or extensive cognitive decline (Borden et al., 2014).

Cognitive changes after DBS are not, however, limited to verbal fluency. One meta-analysis including controlled (albeit not necessarily randomized) studies, reported greater memory decrements in STN DBS groups than controls (Xie, Meng, Xiao, Zhang, & Zhang, 2016). This finding parallels those from earlier controlled studies of STN DBS showing declines in attention and memory (Smeding et al., 2006; York et al., 2008). STN DBS may be associated with small declines in executive function (Parsons, Rogers, Braaten, Woods, & Tröster, 2006), but interestingly, patients may subjectively perceive improved executive functions after DBS (Pham et al., 2015). Overall, recent meta-analyses’ findings are consistent with large randomized, controlled trails showing relatively small declines on a narrow range of tests, and the most robust effects of DBS on verbal fluency.

Psychiatric issues after DBS were addressed in an early meta-analysis (Appleby, Duggan, Regenberg, & Rabins, 2007) but this analysis did not report effect sizes and combined studies of DBS for a variety of conditions and anatomical targets. A very useful, more recent study reviewed rates of various psychiatric complications in trials of medical therapy and STN and GPi DBS using various ascertainment methods (e.g., rating scales, self-report, etc.) (Castrioto, Lhommee, Moro, & Krack, 2014). For depression, based on clinical symptoms, rates at 3–6 months ranged from 0% for BMT to 0%–5% for STN DBS (no estimates at 6 months for GPi DBS). Rates of change were not reported for studies using depression scales, but STN, unlike best medical therapy (BMT), yielded group-wise reductions in symptom severity regardless of scale used. Suicidal ideation rates over 6–24 months ranged from 0.7% to 1.5% for STN DBS and 0%–0.7% for GPi DBS. Completed suicide rates between 6 and 24 months after surgery ranged from 0% to 0.8% for BMT, 0% to 1.3% for STN DBS, and 0.7% for GPi DBS (at 24 months). Apathy was estimated to occur in 1.3%–5% of persons between 3 and 6 months after STN DBS. Psychosis, interestingly, may occur at higher rates in BMT (9%) compared to DBS (2.2%–6%).

Two of the largest and best-designed comparisons of STN and GPi DBS (VA CSP-468 and The Netherlands SubThalamic and Pallidal Stimulation (NSTAPS) study) (Odekerken et al., 2013; Odekerken et al., 2015; Rothlind et al., 2015) and three other controlled studies of STN DBS published detailed neuropsychological follow-up analyses (Foki et al., 2017; Tramontana et al., 2015; Tröster, Jankovic, Tagliati, Peichel, & Okun, 2017). These studies are worth mentioning for their quality and because they were not all included in the meta-analyses. Both of the STN and GPi comparisons are especially useful because they determined reliable changes in neuropsychological functioning after DBS. The follow-up of the CSP-468 study (Rothlind et al., 2015) examined neuropsychological data from 117 BMT, 80 GPi DBS, and 84 STN DBS patients before and 6 months after GPi or STN DBS surgery. Because there were minimal meaningful differences between STN and GPi DBS outcomes (STN performed better on one measure of learning and memory while GPi performed better on one measure of processing speed), the groups were combined for further analyses. Factor analysis disclosed that the neuropsychological tests administered covered five domains: Processing speed, working memory, language, memory, and executive functions. Cognitive change at 6 months was determined on the basis of reliable change indices (RCI) derived from mean change in the BMT control group, and a decline in a domain was defined as reliable change having occurred on at least one-third of the measures used to evaluate the domain (the number of measures/scores per domain varies). Declines in multiple domains were seen in 3% of BMT and 11% of DBS patients 6 months after DBS. Importantly, although those showing and not showing multiple-domain cognitive declines both had significantly improved self-reported functioning and quality of life (QoL), the gain was attenuated in the group with cognitive declines.

The report of the NSTAPS 12-month neurobehavioral outcomes among 62 GPi (3 of 65 subjects withdrew after randomization) and 63 STN DBS (Odekerken et al., 2013) used a broad composite outcome based on loss of important relationships, loss of professional activity, decline per RCI on three or more neuropsychological tests, and diagnosis of anxiety, depression or psychosis for 3 months or more. Among the GPi DBS group, 58% had negative neurobehavioral composite scores (at least one of the listed adverse behavioral events), while 56% of the STN DBS group had at least one of the four negative neurobehavioral indicators within 12 months of surgery. Cognitive decline (per RCI on at least three measures) occurred in 27% of GPi and 35% of STN DBS (a nonsignificant difference). More specific 12-month neuropsychological test data (available for 58 GPi and 56 STN DBS patients) were published in a follow-up paper (Odekerken et al., 2015). Despite having administered multiple tests, many with multiple scores, only Stroop task word reading and color naming (but not interference) and Trailmaking Part B declined more in the STN than GPi DBS group. Using the composite of changes on at least 3 of 12 tests per RCI, 29% of GPi, and 39% of STN experienced declines 12 months after surgery (no significant differences between GPi and STN DBS). Cognitive decline was associated with older age but not, unlike in the VA cooperative study, with QoL changes.

Several other trials again have shown circumscribed cognitive declines after STN DBS. One study of 18 STN DBS patients compared cognitive changes on the Neuropsychological Test Battery Vienna short-form over 12 months in that group against changes in 25 PD undergoing BMT, 24 MCI (non-PD), and 12 healthy control subjects (Foki et al., 2017). Using RCI, 11% of the DBS group, but none of the BMT group showed phonemic verbal fluency declines. In a comparison of neuropsychological changes in 101 PD patients 3 months after STN DBS, and in 35 patients who had STN electrodes implanted but stimulation had not yet been activated, both groups showed decrements in semantic and switching verbal fluency (Tröster et al., 2017). Only the stimulation group evidenced a decline in phonemic verbal fluency and on the Stroop task (suggesting these declines may be related to either stimulation or a combination lesion and stimulation effect). The stimulation group, however, evidenced more frequent improvements in depressive symptomatology than the delayed activation control group.

One recent report is of note because it documented neuropsychological outcomes of bilateral STN DBS in 15 patients early in the disease (i.e., these patients had been treated with antiparkinsonian medication for 6 months to 4 years). The outcomes after DBS were compared to those in a group of 15 early PD patients who underwent BMT (Tramontana et al., 2015). The STN DBS group showed greater declines at 12 months in phonemic fluency, digit span, and on the Stroop task, and lesser gains on the Wisconsin Card Sorting Test (WCST perseverative errors) and some trials of the Paced Auditory Serial Addition Test (PASAT). Overall, then, cognitive changes after DBS appear to be qualitatively similar in early and advanced PD, with the most obvious changes seen in fluency and executive functions.

8.18.2.4.4 The Assessment of Pain Behavior

The description of pain behavior has been systematized using specific observational guidelines (Keefe et al., 2011) although less resource intensive behavioral rating scales have also been developed (Cook et al., 2013), and there are specific tools for the assessment of pain in children and adolescents.

A disjunction has been found between objective and self-report measures of activity suggesting that different mechanisms may be involved (Huijnen et al., 2011) and there is evidence for the functional distinctiveness of pain expression and activity intolerance. The similarity of facial expression of pain in humans and other animals has been taken as evidence for evolutionary accounts of pain communication (Williams, 2002) and as an example of cross species translation in pain research (Chambers and Mogil, 2015). These analyses have been extended into studies of communication (Craig et al., 2011), empathy (Goubert et al., 2011) and intimacy (Cano and De C Williams, 2010). Clinically, the role of significant others has been a major building block of the behavioral approach to pain management (Fordyce, 1976; Main et al., 2015).

Brief Psychiatric Rating Scale

The Brief Psychiatric Rating Scale (BPRS) was originally developed by Overall and Gorham (1962) and continues to be among the most popular behavioral rating scales in use today (Hafkenscheid, 1993). The authors developed the BPRS to provide a standardized method to assess changes in symptoms in response to medications in outcome studies. However, since its development, it has had widespread application for clinical and research purposes in both inpatient and outpatient settings to assess individuals with a variety of psychiatric disorders. The original BPRS had 16 items representing common psychiatric symptoms such as positive and negative psychosis, mania and depression, anxiety, and somatic disturbances. Since then, important modifications have been made to the original version, including increasing the number of items to increase symptom coverage. To improve reliability and validity of ratings, more detailed operational definitions for items and behavioral anchors to assist in establishing symptom severity were developed. A variety of semistructured interviews were also written to assist with administration and ensure more uniform coverage of information across evaluators (Bigelow & Murphy, 1978; Lukoff, Nuechterlein, & Ventura, 1986; Overall, Hollister, & Pichot, 1967).

The most recent version of the BPRS is referred to as the BPRS extended version (4.0). It consists of 24 items rated on a seven-point Likert-type scale. A rating of “1” indicates the absence of symptoms, ratings of “2–3” indicate “very mild” to “mild” symptoms that are considered to have nonpathological intensity, and ratings of “6–7” indicate “severe” or “extremely severe” symptoms associated with significant distress or impairment (Ventura et al., 1993). To improve reliability, guidance is provided regarding the sources of information used to complete each item, with some items based on self-reported symptoms and others based on behavioral observation of the client during the interview. Symptoms are rated for the 2-weeks preceding the assessment. A total score is calculated by summing ratings across all items, but subscales scores are sometimes calculated based on factor analytic studies indicating the BPRS assesses several symptom domains which is expected given the multidimensional nature of the scale. The extended version of the BPRS and supporting materials are contained in Ventura et al., 1993. A child version of the BPRS is also available, the BRPS-C (Overall & Pfefferbaum, 1982; Shafer, 2013).

Psychometric investigations of various BPRS versions provided evidence for satisfactory to excellent interrater reliability (Hafkenscheid, 1993; Lachar et al., 2001; Roncone, Ventura, Impallomeni, Fallon, & Morosini, 1999; Ventura et al., 1993; Zanello, Berthoud, Ventura, & Merlo, 2013). There is also evidence for satisfactory validity based on score correlations with other rating scales (Inch, Crossley, Keegan, & Thorarinson, 1997; Morlan & Tan, 1998) and longitudinal sensitivity to changes in psychiatric symptoms (Zanello et al., 2013). There has also been substantial interest in the factor structure of the BPRS given that it is a multidimensional rating scale and as a result, interpretation of its total score may be less meaningful than interpretation of subscale or factor scores. Interpretation of subscales or factors scores were hampered to some degree by divergent results from factor analytic studies that report four, five, and sometimes six factor solutions (e.g., Dingemans, Linszen, Lenior, & Smeets, 1995; Mueser, Curran, & McHugo, 1997; Zanello et al., 2013). The most likely contributors to different solutions reported across studies include item number and content of the BPRS versions, type of factor analysis used, and sample characteristics (Shafer, 2005).

Despite these differences, the original four-factor model suggested by Overall et al. (1967) held reasonably well. This model includes Anxious Depression, Hostile Suspiciousness, Thought Disturbance, and Withdrawal Retardation symptom domains. Also, examination of subscale scores proved more effective than the total score for distinguishing between various psychiatric disorders and for determining changes in specific symptom domains to help inform treatment and judge its effectiveness (Lachar et al., 2001; Long & Brekke, 1999; Nicholson, Chapman, & Neufeld, 1995; Van der Does, Dingemans, Linszen, Nugter, & Scholte, 1995). A meta-analysis conducted by Shafer (2005) of 26 factor analytic studies of the 18-item BPRS identified four core factors, and an additional fifth factor. The five factors and BPRS items that load on them are presented in Table 12.1.

Table 12.1. Factor structure of the 18-item BPRS from Shafer (2005) meta-analysis

For the four core factors, item loadings were strong on each respective factor with little cross loading. When the fifth factor was added (Activation), the mannerisms and posturing and tension items formed a factor with the excitement item, but the items exhibited cross loadings on other factors, thereby prompting questioning of the validity of the Activation factor. There is less consistency regarding the factor structure of the extended 24-item version of the BPRS. However, it may be said that there is general consistency for the affect, positive symptoms, negative symptoms, and resistance factors for the 18-item BPRS and some confidence may thus be placed in these factor scores. Less confidence is warranted for factors such as Activation, Disorganization, and Somatization, which are identified in some studies but not in others, may not attain simple structure, and at times include items that do not seem to be conceptually related (e.g., see activation factor in Table 12.1). Thus, interpretation of factor scores should focus on the four core factors identified by Shafer (2005) and be qualified based on the factor structure (and study) from which they were derived.

5.20.3.1 Multimodal Assessment

Appraisal of core CD symptomatology is a significant facet of assessment. For younger children, the main sources of information about conduct problems are parents and teachers via behavioral rating scales. Direct observation of child behavior in social settings (e.g., home, classroom, playground) can also provide useful data about interactive style, particularly with respect to interpersonal aggression. Structured diagnostic interviews of the caregiver have potential utility with younger and older children. For older children, youth report via self-report instruments (behavioral rating scales, behavioral incident checklists) and structured diagnostic interviews add breadth to the assessment of conduct problems.

Several rating scales have acceptable psychometric properties and adequate coverage of content pertinent to conduct disorder. The Child Behavior Checklist, a 113-item instrument, covers youth ranging from 2–16 years of age and has versions for parent, teacher, and youth report (Achenbach & Edelbrock, 1983). The Conners Parent and Teacher Rating Scales are a collection of instruments varying in length and specificity which are particularly useful for assessing comorbid ADHD as well as nuances of conduct problems and antisocial behavior (Conners, 1969, 1970, 1973; Goyette, Conners, & Ulrich, 1978). The Eyberg Child Behavior Inventory, a 36-item instrument designed specifically to assess aspects of conduct and oppositional problems in youth aged 2–16 years, is particularly useful for pinpointing problem areas and assessing treatment effects (Eyberg, 1992; Eyberg & Robinson, 1983; Eyberg & Ross, 1978).

Some intervention programs rely on direct observation, either in the home or in a clinic analogue setting, as a basis for characterizing the specific nature of the problems and for driving treatment implementation (Patterson, 1982; Sanders, Dadds, & Bor, 1989). With younger children, such observations may involve family tasks that involve free play by children and transition tasks that place demands on them. With older children, the observation tasks tend to take the form of problem-discussion tasks for families to attempt. In general, observation seems to be particularly useful for assessing key family processes and other interpersonal interactions (e.g., playground interactions) that might bear on the maintenance of CD, rather than for trying to establish rates and extent of conduct problems.

A major challenge in assessing conduct problems is the variability in types of symptoms that youth with CD can exhibit. While most of the younger children early-onset CD group exhibit demonstrative aggression towards others in public settings, the older youth are more variable. Some adolescents who clearly qualify for a CD diagnosis exhibit little or no overt aggression towards others but instead commit covert acts such as vandalism, cruelty to animals, or nonconfrontational theft. Others only commit aggressive acts in specific circumstances, such as in coercive sexual encounters. The implication of this variability is that there is no single constellation of symptoms to monitor for all youth with CD.

Pain assessment

Working definition

Case formulation has been construed as the clinician's conceptual framework for understanding and correcting the patient's problems (Ingram, 2012). Case formulation from a science-based perspective is an ongoing iterative process consisting of the following three primary activities: (a) data collection; (b) hypothesis generation; and (c) hypothesis testing. A second important assumption of science-based case formulation is that these three activities reciprocally influence each other. For example, early clinical hypotheses about the patient's core problems are likely to undergo modifications as a function of the incoming data from various sources (e.g., clinical interview, patient-rating scales, behavioral observation, and information from significant others). Similarly, as certain clinical hypotheses undergo testing, many may be jettisoned and replaced with new ones. In turn, the testing of these new hypotheses may require the introduction of new assessment measures and the discarding of others.

Obviously, the strategies for testing clinical hypotheses involve more than the collection and interpretation of the data. Just as experimental manipulation of putative causal factors is a powerful tool for scientific discovery, the introduction of various treatment elements in therapy and their corresponding effects on the patient's symptoms, function as a powerful tool for evaluating one's clinical case formulation.

Up to now we have been discussing clinical hypotheses and their testing more generally. Not surprisingly, effective case formulation requires some degree of specificity for achieving its overarching objective of developing an accurate conceptual framework for understanding and correcting the patient's problems. Clinical hypotheses can be construed as tentative answers to relevant questions related to the nature, severity, causes, possible therapeutic interventions, and their efficacy (Table 1).

Table 1. Typical questions governing relevant hypothesis testing for case formulation

A third and crucial feature of science-based case formulation is the integration of prior research findings in guiding the generation of tentative hypotheses about diagnoses, current maintaining factors, selection of assessment strategies and measures, and selection of intervention strategies.

The Role of DHA

DHA makes up around 25% of the dry volume of brain cells in all healthy mammals and concentrates in neuronal synapses,11 where, in conjunction with proteins, it modulates the synthesis, transport and release of monoamine neurotransmitters.12 The results of a retrospective study examining the RBC EFAs in ADHD, autism and typically developing children are shown in Tables 14.1 and 14.2.13 The Australian Twin Behavioural Rating Scales (revised) is a DSM-IV behavioral screening questionnaire for ADHD, and the Test of Variables of Attention (TOVA) is a computer-administered continuous performance task.

Table 14.1. Means and Standard Deviations of Age, TOVA, ATBRS, CARS, EPA, DHA and AA Between Typically Developing, ADHD and ASD Groups

EPA, eicosapentaenoic acid; DHA, docosahexaenoic acid; AA, arachidonic acid; ADHD, attention deficit hyperactivity disorder; ASD, autism spectrum disorder; TD, typically developing; TOVA, Test of Variables of Attention; ATBRS, Australian Twin Behaviour Rating Scales; CARS, Childhood Autism Rating Scale.

Table 14.2. Independent Sample t-test Scores of EPA, DHA and AA in ADHD and ASD Groups Compared to a Typically Developing Sample

EPA, eicosapentaenoic acid; DHA, docosahexaenoic acid; AA, arachidonic acid.

Note the dramatically low percentage of RBC DHA in children with autism compared to those with ADHD and typically developing controls. The optimum RBC DHA level is>6%, and is achievable with a diet high in fatty cold-water fish or fish oil supplementation. In addition, children with autism spectrum disorder (ASD) had very low RBC AA, suggesting impaired cell membrane integrity, and therefore vulnerability to damage from toxins and antigens.13

These results indicate that children with ASD had by far the worst EFA profile, and those with ADHD were lagging behind their typically developing peers. Given that DHA modulates the synthesis, transport and release of neurotransmitters in synapses, this is not surprising. However, many of the children with autism and ADHD had RBC DHA as low as 0.1%, while others had ratios around 4.0%. These large fluctuations suggest that whereas DHA deficiency may constitute a major part of the etiology of neurodevelopmental disorders, other factors are also at play. During treatment, optimum levels (>6.0%) are achieved by aggressive supplementation with high-quality fish oil concentrate. Maintenance after 12 months can be achieved by consuming oily fish four or more times a week. However, our experience has shown that this is applicable only for some children. Others seem to need to take fish oil supplements and nutrient cofactors permanently. This is probably a result of the irreversible downregulation of desaturase stages, as previously discussed.9 A comprehensive review of all the nutrients and enzyme cofactors involved in brain function is beyond the scope of this chapter. Therefore, only an overview of those that have been shown to be involved in the attentional system and in mood regulation is provided next.