Use of outcome measurements in clinical practice: How specific should one be?

OBJECTIVE: Progress feedback is often measured with generic instruments that measure common symptoms and generic aspects of functioning. The current study aims to explore the relative usefulness of disorder-specific measures. We hypothesized that disorder-specific instruments reveal more improvement than generic instruments and that the addition of disorder-specific instruments results in better treatment outcomes. METHOD: We used a cohort of 3419 patients with a depression. As generic measures, we used the BSI or the symptoms distress subscale of the OQ-45. In 946 patients, a specific instrument, the IDS-SR, was added. We compared mean change scores and percentages of clinical significant change. In a matched case control design, we analyzed whether the additional use of the IDS-SR resulted in better treatment outcomes. RESULTS: Mean change scores of both types of instruments were comparable. When comparing clinical significant change, agreement was moderate. We found better outcomes on the generic instruments when both a generic and a disorder-specific instrument were used. CONCLUSION: In individual treatment of depression, generic and disorder-specific instruments are not interchangeable. The additional use of disorder-specific instruments provides a more complete picture of the patient's progress than the use of a generic instrument alone. Clinical or methodological significance of this article: In outcome management often rather generic instruments are used, that do not address the specific symptoms of the primary diagnosis of patients. In daily practice clinicians do not always use the feedback on treatment progress, when they perceive the feedback as not specific or relevant enough. The current study aims to explore the relative usefulness of measures that focus on symptoms that characterize the primary diagnosis of patients with a depression compared to the generic measures. We used a large cohort of existing data of patients of several mental health care organizations that share an application for outcome measurement. First, we compared outcomes of generic instruments and a disorder-specific instrument of a subsample of patients with a depressive disorder that completed both kinds of instruments. Next, we applied a matched case control design to control for differences between patients and analyzed whether the additional use of disorder-specific instruments predicted better outcomes. With this methodology, we tried to optimize both the methodological quality as well as the clinical significance of our research.

Denoting treatment outcome in child and adolescent psychiatry: a comparison of continuous and categorical outcomes.

Various approaches have been proposed to denote treatment outcome, such as the effect size of the pre-to-posttest change, percentage improvement, statistically reliable change, and clinical significant change. The aim of the study is to compare these approaches and evaluate their aptitude to differentiate among child and adolescent mental healthcare providers regarding their treatment outcome. Comparing outcomes according to continuous and categorical outcome indicators using real-life data of seven mental healthcare providers, three using the Child Behavior Checklist and four using the Strengths and Difficulties Questionnaire as primary outcome measure. Within each dataset consistent differences were found between providers and the various methods led to comparable rankings of providers. Statistical considerations designate continuous outcomes as the optimal choice. Change scores have more statistical power and allow for a ranking of providers at first glance. Expressing providers' performance in proportions of recovered, changed, unchanged, or deteriorated patients has supplementary value, as it denotes outcome in a manner more easily interpreted and appreciated by clinicians, managerial staff, and, last but not least, by patients or their parents.

Gender-Specific Developmental Trajectories of Anxiety during Adolescence: Determinants and Outcomes. The TRAILS Study.

OBJECTIVE: To identify developmental trajectories of anxiety symptoms for adolescent girls and boys. Trajectories were compared with regard to early-adolescent risk factors and psychiatric outcomes during adolescence and in young adulthood. METHOD: A community sample of 2,230 adolescents was assessed three times across a six-year interval (10-17 years). Symptom scores of anxiety were analyzed with growth mixture models, stratified by gender. RESULTS: Three gender-specific anxiety trajectories were identified for both girls (93.3% low, 4.1% mid-adolescence limited, 2.6% mid-adolescence increasing) and boys (84.4% low, 9.5% mid-adolescence limited, 6.1% early-adolescence decreasing). Child, family and peer factors at baseline predicted group membership of the mid-adolescence limited anxiety trajectory and the early-adolescence decreasing anxiety trajectory in boys. Parental emotional problems predicted the early-adolescence anxiety increase trajectory in girls. Prevalence of anxiety disorders and depression during adolescence and in early adulthood was higher in both the mid-adolescence limited and the mid-adolescence anxiety increase trajectory. CONCLUSIONS: The longitudinal course of anxiety symptoms during adolescence was characterized by three distinct gender-specific developmental trajectories. The most at-risk trajectory in girls was the mid-adolescence anxiety increase trajectory, and in boys the mid-adolescence limited trajectory. None of the environmental (i.e., child, family and peer) factors distinguished the at-risk trajectories from the other trajectories.

Résumé OBJECTIF: Identifier les trajectoires développementales des symptômes d'anxiété pour les adolescents et les adolescentes. Les trajectoires ont été comparées à l'égard des facteurs de risque du début de l'adolescence et des résultats psychiatriques durant l'adolescence et le jeune âge adulte. MÉTHODE: Un échantillon communautaire de 2 230 adolescents (de 10 à 17 ans) a été évalué à trois reprises sur un intervalle de six ans. Les scores des symptômes d'anxiété ont été analysés à l'aide de modèles de croissance mixtes, stratifiés par sexe. RÉSULTATS: Trois trajectoires d'anxiété sexospécifiques ont été identifiées pour les filles (93,3 % faibles, 4,1 % limitées à la mi-adolescence, 2,6 % croissantes à la mi-adolescence) et les garçons (84,4 % faibles, 9,5 % limitées à la mi-adolescence, 6,1 % décroissantes au début de l'adolescence). Les facteurs environnementaux des enfants, de la famille et des pairs au départ prédisaient l'appartenance du groupe à la trajectoire d'anxiété limitée de la mi-adolescence ainsi qu'à la trajectoire d'anxiété décroissante du début de l'adolescence chez les garçons. Les problèmes émotionnels parentaux prédisaient la trajectoire d'anxiété croissante du début de l'adolescence chez les filles. La prévalence des troubles anxieux et de la dépression durant l'adolescence et au jeune âge adulte était plus élevée tant dans la trajectoire d'anxiété limitée de mi-adolescence que dans la trajectoire d'anxiété croissante de mi-adolescence. CONCLUSIONS: L'évolution longitudinale des symptômes d'anxiété durant l'adolescence était caractérisée par trois trajectoires développementales sexospécifiques distinctes. Chez les filles, la trajectoire la plus à risque était la trajectoire d'anxiété croissante de mi-adolescence, et chez les garçons, la trajectoire d'anxiété limitée de mi-adolescence. Aucun des facteurs environnementaux (c.-à-d., enfants, famille, pairs) ne distinguait les trajectoires à risque des autres trajectoires.

Childhood problem behavior and parental divorce: evidence for gene-environment interaction.

OBJECTIVE: The importance of genetic and environmental influences on children's behavioral and emotional problems may vary as a function of environmental exposure. We previously reported that 12-year-olds with divorced parents showed more internalizing and externalizing problems than children with married parents, and that externalizing problems in girls precede and predict later parental divorce. The aim of the current study was to investigate as to whether genetic and environmental influences on internalizing and externalizing problems were different for children from divorced versus non-divorced families. METHODS: Maternal ratings on internalizing and externalizing problems were collected with the Child Behavior Checklist in 4,592 twin pairs at ages 3 and 12 years, of whom 367 pairs had experienced a parental divorce between these ages. Variance in internalizing and externalizing problems at ages 3 and 12 was analyzed with biometric models in which additive genetic and environmental effects were allowed to depend on parental divorce and sex. A difference in the contribution of genetic and environmental influences between divorced and non-divorced groups would constitute evidence for gene-environment interaction. RESULTS: For both pre- and post-divorce internalizing and externalizing problems, the total variances were larger for children from divorced families, which was mainly due to higher environmental variances. As a consequence, heritabilities were lower for children from divorced families, and the relative contributions of environmental influences were higher. CONCLUSIONS: Environmental influences become more important in explaining variation in children's problem behaviors in the context of parental divorce.

Trajectories of CBCL attention problems in childhood.

The first aim of this study was to identify developmental trajectories of Attention Problems in twins followed from age 6 to 12 years. Second, we investigated whether singletons follow similar trajectories. Maternal longitudinal ratings on the Attention Problems (AP) subscale of the Child Behavior Checklist were obtained for a sample of 12,486 twins from the Netherlands Twin Register and for a general population sample of 1,346 singletons. Trajectories were analyzed by growth mixture modeling in twins, and compared with singletons. Teacher ratings on the AP subscale of the Teachers' Report Form were available for 7,179 twins and 1,211 singletons, and were used for cross-sectional mean comparisons at each age. All analyses were conducted for boys and girls separately. We identified three linear trajectories in both boys and girls, i.e., stable low (62-71%), low-increasing (15-18%), and high-decreasing (14-21%). Singletons followed three identical trajectories, with similar class proportions. Teacher ratings yielded no differences in mean levels of Attention Problems between twins and singletons. The development of Attention Problems from age 6 to 12 years can be characterized by stable low, low-increasing, and high-decreasing developmental trajectories. Twins and singletons are comparable with respect to the development of Attention Problems in childhood.

Pre-divorce problems in 3-year-olds: a prospective study in boys and girls.

OBJECTIVE: We examined to what extent internalizing and externalizing problems at age 3 preceded and predicted parental divorce, and if divorce and the time lapse since divorce were related to internalizing and externalizing problems at age 12. METHODS: Parental ratings of internalizing and externalizing problems were collected with the Child Behavior Checklist (CBCL) in a large sample (N = 6,426) of 3-year-old children. All these children were followed through the age of 12 years, at which parents completed the CBCL again, while teachers completed the Teacher's Report Form. Children whose parents divorced between age 3 and age 12 were compared with children whose families remained intact. RESULTS: Girls whose parents divorced between ages 3 and 12 already showed more externalizing problems at age 3 than girls whose parents stayed married. Higher levels of externalizing problems in girls at age 3 predicted later parental divorce. Parental reports indicated that 12-year-olds with divorced parents showed more internalizing and externalizing problems than children with married parents. Levels of teacher-reported problems were not different between children with married versus divorced parents. However, children whose parents divorced between ages 3 and 12 showed more teacher-rated internalizing problems at age 12 when the divorce was more recent than when the divorce was less recent. Parental ratings of both internalizing and externalizing problems at age 12 were not associated with the time lapse since divorce. CONCLUSION: Externalizing problems in girls precede and predict later parental divorce. Post-divorce problems in children vary by raters, and may depend on the time lapse since divorce.

A twin-singleton comparison of developmental trajectories of externalizing and internalizing problems in 6- to 12-year-old children.

Research on twin-singleton differences in externalizing and internalizing problems in childhood is largely cross-sectional and yields contrasting results. The goal of this study was to compare developmental trajectories of externalizing and internalizing problems in 6- to 12-year-old twins and singletons. Child Behavior Checklist (CBCL) maternal reports of externalizing and internalizing problems were obtained for a sample of 9651 twins from the Netherlands Twin Register and for a representative general population sample of 1351 singletons. Latent growth modeling was applied to estimate growth curves for twins and singletons. Twin-singleton differences in the intercepts and slopes of the growth curves were examined. The developmental trajectories of externalizing problems showed a linear decrease over time, and were not significantly different for twins and singletons. Internalizing problems seem to develop similarly for twins and singletons up to age 9. After this age twins' internalizing symptoms start to decrease in comparison to those of singletons, resulting in less internalizing problems than singletons by the age of 12 years. Our findings confirm the generalizability of twin studies to singleton populations with regard to externalizing problems in middle and late childhood. The generalizability of studies on internalizing problems in early adolescence in twin samples should be addressed with care. Twinship may be a protective factor in the development of internalizing problems during early adolescence.