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

Abstract

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 Child Behavior Checklist (CBCL) and Youth Self Report (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. Demographically diverse youth, 5 to 18 years of age, were drawn from two samples; one (N = 1,084) was recruited from a research center, and the second (N = 651) was recruited from an urban community mental health center. Consensus diagnoses integrated information from semistructured interview, family history, treatment history, and clinical judgment. The CBCL and YSR internalizing problems T scores discriminated cases with any anxiety disorder or with generalized anxiety disorder from all other diagnoses in both samples (ps < .0005); the two scales had equivalent discriminative validity (ps > .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 greater than 69 (CBCL) or greater than 63 (YSR) resulted in a Diagnostic Likelihood Ratio of 1.5; low scores reduced the likelihood of anxiety disorders by a factor of 4. 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 a youth is likely suffering from an anxiety disorder.

Notes

Note: *p < .05. **p < .005. ***p < .0005, two-tailed; based on t-test for continuous variables (age, number of diagnoses) and chi-squared for categorical variables (gender, race, diagnostic group) comparing the academic (Findling et al., 2005; Youngstrom et al., 2005) to the community clinic samples (Youngstrom et al., 2005).

Note: N = 1,735. Findling et al. (2005) used the 1991 version of the Achenbach scales, which did not include the DSM-oriented subscales; Youngstrom et al. (2005) used the 2001 version. ROC = receiver operating characteristic; CI = confidence interval; CBCL = Child Behavior Checklist; DSM = Diagnostic and Statistical Manual of Mental Disorders; YSR = Youth Self-Report.

^a Academic Clinic Area Under the Curve (AUC) significantly greater than Community Clinic AUC (z = 3.03, p = .002). Note that this difference would not survive post hoc correction for number of comparisons.

^b The DSM-Oriented scales were only available in the later protocol (Youngstrom et al., 2005), which used the 2001 version of the Achenbach instruments.

*p < .05. **p < .005. ***p < .0005, two-tailed.

Note: N = 1,735. Findling et al. (2005) used the 1991 version of the Achenbach scales, which did not include the DSM-oriented subscales; Youngstrom et al. (2005) used the 2001 version. ROC = receiver operating characteristic; CI = confidence interval; CBCL = Child Behavior Checklist; DSM = Diagnostic and Statistical Manual of Mental Disorders; YSR = Youth Self-Report.

^a Academic Clinic Area Under the Curve (AUC) significantly greater than Community Clinic AUC (z = 2.08, p = .038). Note that this difference would not survive post hoc correction for number of comparisons.

^b The DSM-Oriented scales were only available in the later protocol (Youngstrom et al., 2005), which used the 2001 version of the Achenbach instruments.

*p < .05. **p < .005. ***p < .0005, two-tailed.

Note: There was no significant difference in the accuracy of the Child Behavior Checklist (CBCL) internalizing in the 5- to 10-year-old age group, Area Under the Curve (AUC) = .66, versus the 11- to 18-year-olds, AUC = .63, z = 0.78, p = .437. Therefore we present one set of likelihood ratios across all ages from 5 to 18 years. Note that T scores already standardize scores based on age and gender norms; the prevalence rate of combined anxiety disorders was 19%. DLR = diagnostic likelihood ratio; YSR = Youth Self-Report.

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