The Child Behaviour Assessment Instrument: development and validation of a measure to screen for externalising child behavioural problems in community setting

Child psychiatric problems are recognized as emerging public health issue throughout the world suggesting a global prevalence of approximately 20% [1]. Behavioural problems are the commonest psychiatric problem among young children [1]. In Sri Lanka, prevalence of behavioural problems among children is reported as 27.2% at the clinical setting accounting second highest category of the psychiatric problems [2]. Young children with behavioural problems are at a greater risk of developing psychiatric disorders in later life [3, 4] and contribute disproportionately to the substantial social and economic burden attributable to mental health problems in the community [5].

The major mediating factors on the pathway to behavioural problems interact with each other over time, and are amenable to effective intervention before problems are stabilized [3]. Because these disorders have a good prognosis if treated at their onset, early identification of such disorders and referral for appropriate care provides an excellent opportunity to improve the mental health of populations [3]. However, early identification and differentiation of such behaviours from normal behaviours is challenging due to the complex and slow rate at which these behaviours manifest and the high overlap of diagnostic categories [6–8]. More over many of the problem behaviours evident during this period are, to some extent, normative and simply reflect developmental changes and stressors [3, 9]. Thus the parents and health care workers have limited ability to identify behavioural problems at an early stage and most children are referred only at an advanced stage of the problem behaviour spectrum [6–8].

Previous studies have shown that childhood behavioural problems are generally first evident in 4-6 years age group [3, 4] during which many children may not present at the clinical setting [8]. Thus screening for behavioural problems targeting this age group at the community level would enhance the early recognition and referral for appropriate care. Furthermore as assessment at the community level can be performed without the direct involvement of a health professional, screening at the community level can be considered more inexpensive than screening at the clinical screening.

Although several instruments exist to identify behavioural problems of children [10–16] most instruments are lengthy, complex, time consuming and have a requirement to be personally administered by trained staff with adherence to specific instructions [17, 18]. The disadvantages inherent to these instruments make them inappropriate for use as routine community screening tools. Thus, there is urgent need for the development of a simple behaviour screening instrument with good psychometric properties that can be used at the grass root level.

The objectives of this study were to develop a screening instrument for early identification of behavioural problems among children aged 4-6 years in the community and to validate the instrument for use in the community setting.

This study was conducted in 2 phases:

Phase 1. Development of the screening instrument by: (a) defining the behavioural problems intended to screen (b) reviewing the available literature for possible items of child behaviour screening instrument (c) constructing a preliminary list of items based on literature review (d) ascertaining the final instrument using Delphi technique.

Phase 2. Assessment of validity and reliability of the final instrument

The main contribution of this study was the successful development of a valid and reliable screening instrument to assess the behavioural problems of children in the community setting. Based on the CBAI score at a cutoff point of 16 or above, 18% of the community sample of children were identified as having a problem behavior. Previous studies have shown satisfactory reliability of maternal and caregiver ratings of behavioural problems of preschool children [32, 33] and the observed prevalence of problem behavior in this sample was consistent with previously reported results [34, 35].

We used several complementary methods to assess the validity of the CBAI, as this provides the most accurate assessment of psychometric properties [28]. Assessment of the face and content validity of the instrument confirmed the conceptual definition had been appropriately translated into operational terms.

The CBAI's sensitivity of 0.88 and specificity 0.81 at the cut off point of >16 compares well with the criterion validity of the other behavioural screening instruments in primary care settings [10–15]. Strength of this study was that the validity of the CBAI was demonstrated in a sample drawn from the community. The fact that the study sample was similar to the population in which the screening instrument was intended to be used resulted in an uninfluenced validation of the instrument, which was not over estimated by extremes of cases nor under estimated by volunteers [29]. Results of the construct validity assessment showed a highly significant difference (p < 0.001) between the CBAI scores obtained by two groups.

These results showed that the Child Behaviour Assessment Instrument (CBAI) is a valid screening instrument. More over as this screening instrument is simple, non invasive, easy to administer imposing minimal discomfort on the children and care givers, can be considered as a test that could be recommended for use at the community level.

This study has several methodological limitations that need to be considered in the interpretation of the results. Although this instrument is intended to screen externalising problems of children aged 4-6 years, we acknowledge that there may be a possibility of leaving out children with internalising problems. However as the internalising problems are considered primarily disorders of adults with some times have late childhood onset, the proportion of undetected children with internalising problems can be considered as minimal [20–23].

A major limitation of this instrument is its retrospective nature of the mothers and caregivers responses on behaviour of the children, introducing the possibility of recall error. However it is likely that this error will be non-differential with respect to the blinded assessment of the Clinical Psychologist and therefore would not have affected the validation assessments undertaken in the study. Previous research suggest that although there is likely to be under reporting due to recall error, responses generally accurately reflect the occurrence of adverse childhood behaviour[36].

The approach employed to assess the reliability of the Child Behaviour Assessment Instrument was to re-administer the instrument to a randomly selected sub sample of 50 (15%) respondents. The major draw back in the test-retest method is the possibility that, during the interval between the two tests occasions the behaviour pattern may change resulting in a lack of consistency that reflect a true change in the subject, rather than a lack of instrument precision. More over, the respondent may remember the responses of the first occasion and simply repeat them on the second occasion, inflating the estimates of the consistency of the responses. In the present study, the CBAI was re-administered after two weeks to balance these potential effects of errors.

Cronbach's alpha as a measure of internal consistency exceeded Nunnaly's criterion of 0.7 for only three sixth of constructs measured. However, some researchers are of the view that a value of 0.5 is adequate to consider as satisfactory correlation [37]. When less stringent criterion of 0.5 is used, the items assessing hyperactivity and impulsivity, abnormalities of communication and restricted, stereotyped behaviour (Cronbach's alpha 0.651-0.691) also can be considered as correlating satisfactorily, confirming the reliability of the instrument.

The CBAI is a valid and a reliable screening instrument that could be used to identify behavioural problems of 4-6 year age children in the community setting of Sri Lanka. The study supports the preliminary use of the CBAI as a screening instrument and associated with further validation studies undertaken in different community settings.

DCS (MBBS, MSc., MD in Community Medicine) is currently holding the position of post doctoral scholar at the Monash University Accident Research Centre. DNF Senior Professor in Community Medicine. HP Professor in Psychological Medicine. RJM Professor in Epidemiology and the Director of Monash University Accident Research Centre. HDS (MBBS, MSc., MD in Community Medicine)