Psychological tests for expectant parents and young children in the Nordic countries: A review of the evidence

Figures & data

Table 1. Criteria for different levels of quality.

	Level 1. Tests with No or a Low Level of Quality	Level 2. Tests with Some Quality	Level 3. Tests with a Good Level of Quality	Level 4. Tests with a High Level of Quality
Number and quality of studies concerning the psychometric properties	No Nordic or international (European or North American) studies OR	a. Only international studies OR b. Nordic studies AND	One Nordic study AND	At least one Nordic study AND
Findings the studies from	No support of the test’s psychometric properties	For a. at least adequate reliability, validity and norms For b.inadequate reliability, validity and norms	at least adequate reliability, validity and norms if used for screening, sensitivity and specificity at least adequate	good or excellent levels of reliability, validity and norms if used for screening, sensitivity and specificity good or excellent

Table 2. Overview of tests for children and their quality ratings.

Name of test	Purpose	Type of test	Used for screening	Quality rating	Evidence of reliability, validity, and norms (Reviewed articles)
Achenbach System of Empirically Based Assessment (ASEBA) Preschool	To assess social skills, emotional and behavioral difficulties, in addition to language delays.	Questionnaire	No	2	Evidence of construct validity is lacking for the age group 0–2 years. No studies on the language sub-test (LDS) were found. (Kristensen et al., 2010)
Ages and Stages Questionnaires (ASQ)	To screen for developmental level including communication, fine and gross motor skills, problem solving, and personal/social development.	Questionnaire	Yes	3	There is some documentation of the reliability of the test, especially the total score. There are also studies supporting the construct validity, and norms exist for some languages. Since the intended test use is screening, more evidence to support this use is needed. (Martinussen & Valla, 2013; Wang et al., 2012; Valla et al., 2017; Østergaard et al., 2012; Vedel et al., 2020)
Ages and Stages Questionnaire: Social and Emotional (ASQ:SE)	To screen for and assess parent-reported social and emotional difficulties in children.	Questionnaire	Yes	2	The reliability seems satisfactory, but there is a lack of Nordic up-to-date norming and validation studies . (Rasmussen & Martinussen, 2013; Vaezghasemi et al., 2020; Eurenius et al., 2019; Squires et al., 2015; Pontoppidan et al. 2017; Velikonja et al., 2016)
Alarm Distress Baby Scale (ADBB)	To screen for infant social withdrawal behavior, to detect signs of congenital, attachment, and relational difficulties.	Observation	Yes	3	Overall good to excellent inter rater reliability. No Nordic articles report on internal consistency and there are no norm studies. Evaluations of the construct validity are based on associations with other instruments and differences between groups. Sample sizes of the included studies were relatively small, especially for some of the samples used for estimating inter-rater reliability. (Moe et al., 2016; Smith-Nielsen et al., 2019; Puura et al., 2007, Puura et al., 2019, Puura et al., 2013, Puura et al., 2010; Guedeney & Fermanian, 2001)
Bayley Scales of Infant and Toddler Development (BSID, BSID-II, BSID-III)	To assess developmental level.	Test incl. equipment	No	2	There are no studies reporting reliability or norms based on Nordic samples, but there are some studies supporting the construct validity of the test. (Richter & Valla, 2013; Månsson & Stjernqvist, 2014; Krogh et al., 2012; Kahr Nilsson et al., 2019; Skovgaard et al., 2008; Sajaniemi et al., 2001)
BOEL (Blik Orienteret Efter Lyd; Glance Oriented After Sound)	To test the child’s interaction, attention and reaction to visual and sound stimuli, in order to identify hearing and communication disorders.	Test incl. equipment	Yes	2	There are no studies reporting the inter-rater reliability. The sensitivity of the BOEL test seems to be rather low. (Rasting & Lindbaek, 1998; Jakobsen et al., 2007; Mortensen et al., 2003; Ravn & Bjerager, 2004; Barr et al., 1978; Barr & Stensland Junker, 1978; Huber et al., 1978),
Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0–5)	Diagnostic classification of mental health and developmental disorders in early childhood.	Interview	No	2	DC: 0–5 is not a traditional assessment tool but a diagnostic multiaxial classification framework that is based on previous versions of the system and work from task force groups combining clinical experience, empirical evidence, and theoretical understandings. (Moe & Mothander, 2009; Mothander & Moe, 2008, Mothander & Moe, 2010; Kahr Nilsson et al., 2019)
Modified Checklist for Autism in Toddlers (M-CHAT) and revised version (M-CHAT-R/F)	To identify early indicators of autism.	Checklist	Yes	3	The internal consistency of the measure is good, and the so is the specificity when predicting diagnoses. The sensitivity is more variable between studies. (Robins et al., 2001; Kleinman et al., 2008; Chlebowski et al., 2013; Nygren et al., 2012, Miniscalco et al., 2018, Robins et al., 2014)
Vane-psy [Vauvan psyykkinen ja neurologinen kehitys]	To monitor the development of infants and toddlers.	Observation/interview	No	3	Sensitivity and specificity are shown to be adequate in one Nordic study, with adequate methodological quality. (Mustonen et al., 2006)

Table 3. Overview of tests for children and parents and their quality ratings.

Name of test	Purpose	Type of test	Used for screening	Quality rating	Evidence of Reliability, Validity and Norms (Related articles)
Ainsworth Strange Situation Procedure (SSP)	To measure mother–child attachment quality and to classify attachment security.	Observation	No	2	Both Nordic and international studies provide inconsistent findings for reliability and validity. No Nordic studies exist about the construct validity. (Heidi, 2015; Lamb et al., 1982; Smith-Nielsen et al., 2016; Hautamäki et al., 2008; Kouvo et al., 2003; Cadman et al. 2018; Van Dam and Van Ijzendoorn, 1988; Fonagy et al., 2016; Luyten et al., 2017; Carcamo et al., 2014)
CARE Index	To screen for and assess adult sensitivity in a dyadic context (child 0–24 months).	Observation	No	2	There are two Nordic studies supporting the inter-rater reliability of the scoring, and some support of the construct validity of the test. However, documentation supporting the use for screening purposes is needed. (Kristensen et al., 2010; Pajulo et al., 2011)
Classroom Assessment Scoring System (CLASS) Toddler	Observational instrument to assess emotional and behavioral support within the classroom.	Observation	No	2	Results revealed adequate measurement quality. However, one study supported a three-domain structure instead of the current two-domain structure in CLASS-T. More research is warranted, especially within the Nordic countries. (Drugli et al., 2018; Bandel et al., 2014; Castle et al., 2016; Thomason & La Paro, 2009; Slot et al., 2017)
Crowell Procedure	Observation of caregiver–child interaction.	Observation	No	2	There is a need for more research examining the psychometric properties of the Crowell Procedure both internationally and in the Nordic countries. (Heller et al., 1999; Loop et al., 2017; Sprang & Craig, 2014)
Lausanne Trilogue Play (LTP)	Observational instrument to assess co-parenting alliance and interactions with the child.	Observation	No	2	There is limited documentation of the different scoring systems used and small sample sizes. (Hedenbro & Rydelius, 2014, Hedenbro & Rydelius, 2019; Hedenbro & Lidén, 2002; Korja et al., 2015,; Korja et al., 2016; Favez et al., 2011)
Marschak Interaction Method (MIM)	To assess parent–child interaction (positive vs. problematic).	Observation	No	2	MIM-P has not been validated for children aged 0–3 years. The existence of several rating systems complicates an overall evaluation of validity and reliability, but there seems to be a need for more research on all ratings systems for the age group 0–3. (Salo & Mäkelä, in press)
Parent–Child Early Relational Assessment (PCERA)	To measure the quality of the parent–child relationship by assessing the affective and behavioral characteristics of their interaction.	Observation	No	2	PCERA has frequently been used in Scandinavian studies (18 publications located in the literature search), but none of the Scandinavian studies were psychometric studies; rather, they were studies where the instrument has been used as a measure of parent–infant interaction for the purposes of the study. Nevertheless, these studies give some limited information of the reliability and validity of the test. No norm studies utilizing Scandinavian samples were found. (Anke et al., 2019; Clark, 1985, Clark, 1999; Haapsamo et al., 2013; Korja et al., 2008, Korja et al., 2010; Lotzin et al., 2015; Misund et al., 2016; Savonlahti et al., 2005.)

Table 4. Overview of tests for parents or adults in general population and their quality ratings.

Name of test	Purpose	Type of test	Used for screening	Quality rating	Evidence of Reliability, Validity and Norms (Related articles)
Adverse Childhood Experiences (ACE)	To measure for adverse experiences before the age of 18	Self-report	No	2	No test-retest reliability studies among our target group, and only one study of internal consistency. In addition to this, a lot of different versions of the test have been used, which indicates a lack of standardization. ACE has been found to correlate with many adverse outcomes among mothers pre- and post-natal, but that cannot be considered as conclusive evidence of construct validity. The majority of the studies were conducted with American samples. (Rohder et al., 2019; Chung et al., 2010; Felitti et al., 1998; Murphy et al., 2014; Steele et al., 2016; Sun et al., 2017).
Alcohol Use Disorders Identification Test (AUDIT)	To screen for harmful or hazardous drinking habits.	Self-report	Yes	2	Overall adequate to good internal consistency. However, results about validity are inconclusive and there is no adequate documentation about sensitivity and specificity. (Selin, 2003; Lund et al., 2019; Lehikoinen et al., 2016; Magnusson et al., 2007; Stene‐Larsen et al., 2013; Comasco et al., 2012; Göransson et al., 2003).
Clinical Outcomes in Routine Evaluation – Outcome Measures (CORE–OM)	To assess mental health symptoms and problems before and after treatment.	Self-report	No	4	Results demonstrated good to excellent reliability and validity for all the Nordic languages examined for both clinical and non-clinical samples. (Honkalmapi et al., 2017; Skre et al., 2013; Kristjánsdóttir et al., 2015; Héðinsson et al., 2013; Elfström et al., 2012).
Domestic Abuse, Stalking and Honor-Based Violence (DASH)	To help identify those at high risk of harm from domestic abuse, and who should be referred to a Multi-Agency Risk Assessment Conference (MARAC) meeting in order to manage the risk.	Interview	Yes	1	Overall, there is limited knowledge about the reliability of DASH and the inter-rater reliability seems to be modest. Low predictive validity. (Chalkey & Strang, 2017; Robinson et al., 2016; Sebire & Barling, 2016; Thornton, 2017; and Turner et al., 2019)
Domestic Violence Filter and Mapping Form	To identify intimate partner and domestic violence	Interview and Questionnaire	No	1	No data on the reliability, validity or norms.
Depression and Anxiety Stress Scale (DASS)	To screen for depression, anxiety and stress.	Self-report	Yes	2	Limited information regarding the translation of the instruments is provided. Internationally, the instrument has been translated into multiple languages and investigated in both clinical and non-clinical samples (e.g., Brown et al., 1997; Crawford & Henry, 2003), and sound psychometric properties are supported. However, more research within the Nordic countries is needed due to the limited documentation of the psychometrics properties, especially the validity of the measure. (Jonsdottir et al., 2017; Dahlerup et al., 2018; Salari et al., 2014; Brown et al., 1997; Crawford & Henry, 2003)
Edinburgh Postnatal Depression Scale (EPDS) – fathers	To measure and screen for depression (postnatal and perinatal).	Self-report	Yes	4	The included studies were of good methodological quality and findings indicate at least adequate internal consistency. Relationships with other instruments were in the expected direction, which supports that the construct validity and documentation about sensitivity and specificity were good. The translation procedures have not been described. (Fredriksen et al., 2019; Edhborg, 2008; Johansson et al., 2017; Kerstis et al., 2013; Kerstis, Nohlert, et al., 2016; Kerstis, Aarts, et al., 2016; Massoudi et al., 2013; Mörelius et al., 2015; Seimyr et al., 2009; Karukivi et al., 2015).
Edinburgh Postnatal Depression Scale (EPDS) – mothers	To measure and screen for depression (postnatal and perinatal).	Self-report	Yes	4	The studies and reviews of EPDS indicated good internal consistency and test-rest reliability. Construct validity in terms of relationships with other relevant instruments was high and in the expected direction, and documentation about sensitivity and specificity was good but varied between studies depending on the cut-off score used, diagnostic method, and possibly sample (post- or perinatal). (Larun et al., 2013; Hanssen-Bauer & Welander-Vatn, 2012; Eberhard-Gran et al., 2001; Rubertsson et al., 2011; Smith-Nielsen et al., 2018; Lydsdottir, Howard, Olafsdottir, Thome, et al.,)
Generalized Anxiety Disorder Scale 2-item (GAD-2)	To screen for generalized anxiety disorder (GAD), and other anxiety disorders.	Self-report	Yes	2	Results were acceptable, but variable, indicating that more research is warranted regarding the accuracy of the GAD-2. Overall, there is limited evidence of psychometric properties in the Nordic countries. Kujanpää et al., 2014; Berge et al., 2019); Plummer et al., 2016)
Generalized Anxiety Disorder Scale 7-item (GAD-7)	To screen for generalized anxiety disorder (GAD), and other anxiety disorders.	Self-report	Yes	4	There is adequate support for the psychometric properties of the test, especially the Finnish language version. There is still a lack of research based on pregnant and postpartum women. (Knapstad et al., 2020; Rozental et al., 2018; Kujanpää et al., 2014; Tiirikainen et al., 2019; Malmberg-Ceder et al., 2019)
Parenting Stress Index (PSI)	To assess parental stress.	Self-report	Yes	3	The majority of Nordic studies are probably conducted on the third edition of PSI, and not the most recent fourth edition. There is considerable evidence supporting the reliability of the test, some studies supporting the construct validity, but norms seem to be lacking for the Nordic languages. (2011; Huhtala et al., 2012; Korja et al., 2014; Landsem et al., 2014; Östberg et al., 1997; Sarfi et al., 2013)
Parents’ Evaluation of Development Status (PEDS©)	To assess children’s development in language, motor skills, self-help, early academic skills, behavior and social-emotional/mental health.	Questionnaire	Yes	2	Overall, there was lack of lack of documentation. No Nordic studies were identified, but according to the test’s webpage, an evaluation of PEDS is ongoing in Iceland. A list of results from the manual implies that PEDS was re-standardized and re-validated in a representative sample in the US and Canada, and different reliability and validity assessments have been conducted; however, no documentation confirming this has been possible to retrieve. Glascoe et al. (2019) reported a sensitivity of 74–96% and specificity of 73–83% for PEDS, which was based on 44 published studies where PEDS was administered correctly, but no information regarding these studies is given, including where they are published. (Glascoe et al., 2019)
Resource form/barometer	To assess resources and strain factors of first-time mothers and fathers.	Self-report	Yes	1	Only the usefulness and necessity of the items were evaluated, not the psychometrics of the questionnaire as such. (Kaljunen et al., 2005)
TWEAK Alcohol Screening Test	To identify pregnant women with harmful drinking habits.	Interview	Yes	2	There were no norms or reliability estimates reported in any of the studies. This, combined with the relatively low sensitivity estimates, suggests insufficient documentation of the psychometric properties. (Præstegaard et al., 2018; Weile et al., 2020)
Vane-psy [Vauvan psyykkinen ja neurologinen kehitys]	To monitor the development of infants and toddlers.	Observation/interview	No	3	Sensitivity and specificity are shown to be adequate in one Nordic study, with adequate methodological quality. (Mustonen et al., 2006)
VAVU – Interview to support early parent–child interaction [Varhaista vuorovaikutusta tukeva haastattelu]	To help identify and address perceptions, concerns, and potential difficulties related to pregnancy, childbirth, and the baby.	Interview	Yes	1	There are no Nordic or international (European or North American) studies examining the psychometric properties
Whooley Questions	To screen for depression (pre- and postnatal).	Self-report	Yes	2	There is a lack of Nordic studies for our target group. No studies reported information regarding test reliability, and the diagnostic accuracy varied a lot between studies, Suija et al., 2012; Bosanquet et al., 2015; Darwin et al., 2016; Howard et al., 2018; Littlewood et al., 2018)
Working Model of the Child Interview (WMCI)	To assess parents’ internal representations (working models) of their relationship to a particular child.	Interview	No	2	There are several international studies providing information on psychometric properties of the WMCI, including a systematic review. However only two Scandinavian (Finnish) studies describing limited psychometric data of the WMCI were found. There were no norm studies based on Scandinavian samples. (Korja et al., 2010; Benoit, Parker et al., 1997; Theran et al., 2005; Vreeswijk et al., 2012; Ainsworth et al., 1978; Zeanah et al., 1994; Main et al., 1985; Zeanah et al., 1994; Korja et al, 2010).

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Data availability statement

The data that support the findings of this study are openly available in https://pub.norden.org/nord2021-037/