Disruptive Behaviour Disorder Rating Scale (DBDRS)

The DBD parent/teacher rating scale is a screening tool designed to aid in the diagnostic process for a number of child psychopathologies, particularly externalising disorders. The DBD rating scale was initially created to further build upon an existing tool created by the same authors, the Swanston, Nolan and Pelham (SNAP) rating scale. The SNAP listed the DSM-III symptoms of attention-deficit disorder (ADD) in a rating scale format. The DSM-III-R brought changes to the diagnostic criteria for attention-deficit hyperactivity disorder (ADHD) and so the authors sought to create a new teacher rating scale to reflect these amendments that would be comparable to the original SNAP rating scale in its effectiveness for providing information required to aid in the diagnostic process. In addition, all three disruptive behaviour disorder categories were included in the new DBD rating scale.

Development

The DBD rating scale consists of 42 items related to symptoms of Conduct disorder (16 items), ODD (8 items), ADHD-Inattention (9 items), ADHD- hyperactivity/ Impulsivity (9 items). These items relate directly to the 36 DSM-III-R diagnostic criteria for Conduct Disorder, Oppositional Defiance Disorder and Attention Deficit Hyperactivity Disorder and are randomly ordered across diagnostic categories. Each item is rated on a four-point scale ranging from not at all (0) to very much (3). Teachers also have the option to check “don’t know” for any item. The DBD rating scale can be used to aid in diagnosis of children in regular classroom settings. There are two ways to determine if a child meets the criteria for DSM diagnoses of Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, or Conduct Disorder. The first method involves counting symptoms for each disorder using the Disruptive Behaviour Disorders (DBD) rating scale. The second method involves comparing the target child’s factor scores on the DBD Rating Scale to established norms. The DBD rating scale has been translated and adapted for the assessment of childhood behavioural problems in Pakistani children. In addition the tool was translated into Georgian using back translation back-translation. The DBD rating scale was also used to generate normative values and percentile charts for Nigerian children.

Psychometric properties

A validation study used a sample of 931 boys that attended regular classrooms aged 5-14 years. Criterion and construct validity was found to be satisfactory. A factor analysis revealed three factors: one reflecting ODD and a number of CD symptoms, one comprised of ADHD impulsivity/overactivity symptoms and one on which ADHD symptoms of inattention loaded highly. Conditional probability analysis revealed several prominent symptoms of ADHD had poor predictive power; contrastively combinations of symptoms from the two ADHD factors had good predictive power. Combinations of ODD symptoms demonstrated very high predictive power.  Due to high teacher ratings of “don’t know”, conduct disorder was found to have lower predictive power. It is anticipated by the authors that the parent rating scale will have a higher predictive power on the CD symptoms. The study also noted that within the elementary school age range oppositional and certain CD symptoms demonstrated a high degree of covariation in the observations by teachers.

The DBD Rating Scale demonstrates good internal consistency for the DSM-III-R categories for Conduct Disorder, Oppositional Defiance Disorder and Attention Deficit Hyperactivity Disorder with coefficient alphas of .81, .95 and .95 respectively.

Use

The tool can be accessed from a number of reputable websites including Researchgate and The Center for School Mental Health website as provided- http://csmh.umaryland.edu/media/SOM/Microsites/CSMH/docs/Resources/ClinicianTools/Summary-of-Free-Assessment-Measures—And-Google-Doc-Link-to-Measures-Saved.pdf

The rating scale is available as a free download, permission is not required, and access is unrestricted.

References

Bzhalava, V., & Inasaridze, K. (2017). Disruptive Behavior Disorder (DBD) Rating Scale for Georgian Population. arXiv preprint arXiv:1702.03409.

Loona, M. I., & Kamal, A. (2011). Translation and adaptation of disruptive behaviour disorder rating scale. Pakistan Journal of Psychological Research26(2), 149.

Ofovwe, G. E., & Ofovwe, C. E. (2010). Disruptive Behaviour Disorder (DBD) Rating Scale for Attention Deficit/Hyperactivity Disorder: Normative Values and Percentile Charts for Nigerian Children Aged 6 to 15 Years. Nigerian Hospital Practice6(1-2).

Pelham, W. E., Gnagy, E. M., Greenslade, K. E., & Milich, R. (1992). Teacher ratings of DSM-III-R symptoms for the disruptive behavior disorders. Journal of the American Academy of Child & Adolescent Psychiatry31(2), 210-218.

Vanderbilt Assessment Scales (VAS)

The Vanderbilt Assessment Scales (parent/teacher) were created in 2002 by the American Academy of Pediatrics (AAP) and the National Initiative for Children’s Healthcare Quality (NICHQ) at the completion of a project aimed to create and implement a model of care for children with ADHD. The VAS is a brief scale completed by parents and teachers that assesses ADHD symptoms of inattention and hyperactivity along with conduct disorder, oppositional defiance disorder, anxiety, depression and academic performance (Fields & Hale, 2011).
Psychometric Properties
The scale has good internal reliability with Cronbach’s alpha coefficient of > .90 (parent) and >.89 (teacher) (Wolraich et al., 2002; Wolraich et al., 2013). Test-retest reliabilities were assessed as adequate (r >.80) (Bard et al., 2013). Interrater reliability, between the two scales is very low (r=.27 – .34) (Wolraich et al., 2002).
The four factor structure of the scale confirms it is a valid measure of inattention, hyperactivity, conduct disorder/oppositional defiance disorder, anxiety/depression. Convergent validity is evidenced by the moderate to high correlations with the Diagnostic Interview Schedule for Children-IV Parent Version (Bard et al., 2013; Collett et al., 2003).
The parent scale produced sensitivity measure (true positives) of 80% and specificity (true negatives) of 75% when predicting a diagnosis of ADHD. However when the parent and teacher scales were combined positive predictive value fell to 19% and the negative predictive value increased to 98% suggesting that the combined scale is very good for identifying children who do not have ADHD (Bard et al., 2013).
The VAS has been used with clinical and community samples of American, African American, Hispanic, Spanish and German children in rural, urban and suburban areas; with those at high and low risk of ADHD. Only small differences were found for gender, age, school grade or severity of ADHD symptoms (Wolraich et al., 2002).
Strengths:
The scale is: easy to complete and score, psychometrically sound, useful for collecting data from multiple sources and assessing academic and behaviour performance (Collett et al., 2003; Kratochvil et al., 2009). It can be used to establish baselines to measure treatment effectiveness (Kratochvil et al., 2009) and has utility to screen for comorbid disorders (Becker et al., 2012; Langberg et al., 2010). The teacher scale correlates highly with a diagnosis of ADHD (Austerman, 2015).
Weaknesses:
There is no evidence found for discriminant validity. Items are more relevant for school aged children than younger. Very low inter-rater reliability between scales and is to be used as a screening tool only.
Clinical utility:
The VAS provides a psychometrically sound method of data collection from both parents and teachers that can be used in the diagnostic process for children with ADHD.  It useful and acceptable to clinicians, readily available and provides assessment of performance and comorbid disorders (Bard et al., 2013).  It is so simple to use, a line can be drawn down the page to delineate meeting or not meeting diagnostic criteria (Molina, 2017).
Link to scale: https://www.nichq.org/resource/nichq-vanderbilt-assessment-scales

References
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.
Austerman, J. (2015). ADHD and behavioral disorders: Assessment, management, and an update from DSM-5. Cleveland Clinic Journal of Medicine, 82, S2-S7.
Bard, D.E., Wolraich, M.L., Neas, B., Doffing, M., & Beck, L. (2013). The psychometric properties of the Vanderbilt attention-deficit hyperactivity disorder diagnostic parent rating scale in a community population. Journal of Developmental and Behavioral Pediatrics, 34, 72-82.
Becker, S.P., Langberg, J.M., Vaughn, A.J., & Epstein, J.N. (2012). Clinical utility of the Vanderbilt ADHD diagnostic parent rating scale comorbidity screening scales. Journal of Development and Behavioral Pediatrics, 33, 221-228.
Collett, B.R., Ohan, J.L., & Myers, K.M. (2003). Ten-year review of rating scales. V: Scales assessing attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 1015-1037.
Fields, S.A., & Hale, L.R. (2011). Psychoeducational groups for youth attention-deficit hyperactivity disorder: a family medicine pilot project. Mental Health in Family Medicine, 8, 157-165.
Kratochvil, C.J., Vaughan, B.S., Barker, A.M.., Corr, L., Wheeler, A., & Madaan, V. (2009). Review of pediatric attention deficit/hyperactivity disorder for the general psychiatrist. Psychiatric Clinics of North America, 32, 39-56.
Molina Healthcare (2017). Behavioral health provider toolkit. Retrieved from: http://www.molinahealthcare.com/providers/common/PDF/Behavioral-Health-Toolkit-for-Specialists.pdf
National Initiative for Children’s Healthcare Quality (2017). Attention Deficit Hyperactivity Disorder (ADHD) Learning Collaborative. Retrieved from: https://www.nichq.org/project/attention-deficit-hyperactivity-disorder-adhd-learning-collaborative
National Initiative for Children’s Healthcare Quality (2017). NICHQ Vanderbilt assessment scales. Retrieved from: https://www.nichq.org/project/attention-deficit-hyperactivity-disorder-adhd-learning-collaborative
Wolraich, M.L., Bard, D.E., Neas, B., Doffing, M., & Beck, L. (2013). The psychometric properties of the Vanderbilt attention-deficit hyperactivity disorder diagnostic teacher rating scale in a community population. Journal of Developmental and Behavioral Pediatrics, 34, 83-93.
Wolraich, M.L., Lambert, W., Doffing, M.A., Bickman, L.B., Simmons, T., & Worley, K. (2003). Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population. Journal of Pediatric Psychology, 28. 559-568.

Adult ADHD Self Report Scale (ASRS) v1.1. Symptom Checklist

The Adult ADHD Self-Report Scale (ASRS) v1.1 Symptom Checklist was developed by the World Health Organisation (WHO) workgroup to provide a valid self-assessment of current ADHD symptoms in adults, as part of the WHO World Mental Health (WMH) Survey Initiative (Kessler et al., 2005). The scale consists of 18 items that correspond directly to the 18 DSM-IV symptoms (for both inattention and hyperactivity). The items were deliberately worded to reflect ADHD symptoms in a more suitable context for adults. For instance, references to “play” and “schoolwork” (in the DSM-IV) have been replaced by “work” and “boring or difficult project” respectively. For each item, respondents are required to indicate how often a particular symptom of ADHD has occurred to them over the past six months on a five-point response scale ranging from 0 – 4 (0 “never”, 1 “rarely”, 2 “sometimes”, 3 “often” and 4 “very often”). The focus on frequency rather than severity of symptoms was to make scale instructions easier for participants to understand. The ASRS does not utilize total or scale scores to indicate diagnostic likelihood. Instead, the authors of the scale recommend counting the number of items the respondent endorses that fall into the gray shaded boxes. Frequency count was recommended over summation of response scores to account for the difference in the weight of responses (e.g., respondents may be more reluctant to admit the frequent occurrence of some symptoms more than others. If the symptom count is 9 or greater, the respondent may need to be referred for further evaluation. Part A of the scale consists of 6 of the most predictive items and has been proposed by the authors for use as a short-form screener (ASRS v1.1 Screener). The authors also suggested that four or more responses within the grey shaded boxes within Part A warrants further investigation.

Developed in the US, the ASRS was originally validated for use in an adult population (>18 years; Kessler et al., 2005; Adler et al., 2006), although a subsequent validation study (Alder et al., 2012) further extended its utility beyond adults to adolescences (13-17 years). The initial validation study by Kessler and colleagues was conducted with a community based sample of adults in US. 154 participants (no childhood ADHD, some symptoms in childhood, diagnosis in childhood but deny current symptoms, diagnosis in childhood and endorse current symptoms) completed a structured, clinician-administered interview of current ADHD symptoms, followed by the ASRS. The authors found adequate sensitivity (56.3%), excellent specificity (98.3%), excellent total classification accuracy (97.9%) and adequate κ value (0.58). Further evidence for the use of the ASRS was found in a clinical population of 60 ADHD adults. The study (Adler et al., 2006) found high internal consistency (0.84) and concurrent validity with a clinician-administered ADHD rating scale (0.83). The 6-item screening version of the ASRS as also been found to possess strong psychometric properties in a cross-validation study on a representative sample of 668 health plan members (Kessler et al., 2007). Researchers of the study for a high internal consistency (0.63-0.72) and test-retest reliability (0.58-0.77).

The ASRS has also been translated to 10 different languages (e.g., Chinese (Mandarin), Dutch, German, Japanese, Portuguese, Russian, and Spanish) although only some of the translated scales have been cross-culturally validated. For example, the Chinese ASRS was found to have high internal consistency (0.83∼0.91) and concurrent validity (0.37∼0.66) with a sample of Taiwanese adults (Yeh et al., 2008) A cross-cultural validation study (of the Korean version of ASRS also found the tool to be psychometrically sound in a Korean sample (Kim, Lee & Joung, 2013).

A growing body of literature supports the use of a ASRS as a screening tool in both general (e.g., Hine et al., 2012)  and clinical populations (such as substance-abuse disorders e.g., Dakwar et al., 2012). In particular, its item working appears to be face valid, and appropriate for tapping the expression of ADHD symptoms in adults (albeit based on the DSM-IV). The scale is free (https://add.org/wp-content/uploads/2015/03/adhd-questionnaire-ASRS111.pdf ) and numerous non-English translations are available. Its brevity and simplicity also means its easy to administer and score. It appears to be widely use for both clinical and research purposes (e.g., Herrmann et al., 2009; Reuter, Kirsch & Hennig, 2006). The ASRS is, however, not a diagnostic tool. In particular, it does not provide information on childhood symptoms, which is necessary in making an ADHD diagnosis. The scale also only assesses frequency – not the functional impact – of symptoms. Hence it is more suitable as a screening or symptom tracking tool and should not be used as the sole basis for clinical diagnosis.

References

Adler, L. A., Spencer, T., Faraone, S. V., Kessler, R. C., Howes, M. J., Biederman, J., & Secnik, K. (2006). Validity of pilot Adult ADHD Self-Report Scale (ASRS) to rate adult ADHD symptoms. Annals of Clinical Psychiatry, 18(3), 145-148.

Kessler, R. C., Adler, L., Ames, M., Demler, O., Faraone, S., Hiripi, E. V. A., … & Ustun, T. B. (2005). The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychological medicine, 35(02), 245-256.

Kessler, R. C., Adler, L. A., Gruber, M. J., Sarawate, C. A., Spencer, T., & Van Brunt, D. L. (2007). Validity of the World Health Organization Adult ADHD Self‐Report Scale (ASRS) Screener in a representative sample of health plan members. International journal of methods in psychiatric research, 16(2), 52-65.

Yeh, C. B., Gau, S. S. F., Kessler, R. C., & Wu, Y. Y. (2008). Psychometric properties of the Chinese version of the adult ADHD Self‐report Scale. International journal of methods in psychiatric research, 17(1), 45-54.

Kim, J. H., Lee, E. H., & Joung, Y. S. (2013). The WHO Adult ADHD Self-Report Scale: reliability and validity of the Korean version. Psychiatry investigation, 10(1), 41-46.

Dakwar, E., Mahony, M. A., Pavlicova, M., Glass, M. A., Brooks, M. D., Mariani, J. J., … & Levin, F. R. (2012). The utility of attention-deficit/hyperactivity disorder screening instruments in individuals seeking treatment for substance use disorders. The Journal of clinical psychiatry, 73(11), e1372.

Hines, J. L., King, T. S., & Curry, W. J. (2012). The adult ADHD self-report scale for screening for adult attention deficit–hyperactivity disorder (ADHD). The Journal of the American Board of Family Medicine, 25(6), 847-853.

Herrmann, M. J., Saathoff, C., Schreppel, T. J., Ehlis, A. C., Scheuerpflug, P., Pauli, P., & Fallgatter, A. J. (2009). The effect of ADHD symptoms on performance monitoring in a non-clinical population. Psychiatry research, 169(2), 144-148.

Reuter, M., Kirsch, P., & Hennig, J. (2006). Inferring candidate genes for attention deficit hyperactivity disorder (ADHD) assessed by the World Health Organization Adult ADHD Self-Report Scale (ASRS). Journal of neural transmission, 113(7), 929-938.

Swanson, Nolan, and Pelham, Version IV Scale-Teacher Form (SNAP-IV)

The SNAP-IV is a questionnaire developed in the US, initially to the standards of the DSM III, to screen for Attention Deficit Hyperactive Disorder, Oppositional Defiance Disorder, as well as overlapping symptoms of all other psychiatric disorders of childhood. It has a short and longer, more comprehensive form, which contains 90 items and includes all of the previously mentioned constructs. The short form, referred to as the MTA version, has 26 items and measures the core ADHD symptoms of impulsivity, hyperactivity, inattention, and a few ODD symptoms. While either can be used in both the clinical and research setting, the MTA version seems to be more commonly used because of its brevity and its ability to measure the core aspects of ADHD. It is designed to be filled out by either the parent or teacher of an elementary school aged child.

The most recent study on the SNAP-IV (MTA version) re-evaluated the psychometric properties of the scale. Factor analysis indicated that the SNAP-IV loads on 3 factors. This matches the framework guiding its construction. Two factors for ADHD emerged – impulsivity/hyperactivity and inattention, while the third one was for ODD. The authors compared the results of the scale with the Diagnostic Interview Schedule for Children, Parent Version (DISC-IV-P), which bases its diagnosis on the DSM-IV and explores functioning in both the home and at school. There is suitable predictive validity support for the SNAP-IV when screening for ADHD.

As for reliability, the study demonstrated that it had acceptable reliability figures. They computed for the reliability figures for the parent and teacher ratings separately, as well as producing subdomain alphas for each factor. The coefficient alpha for overall parent ratings was .94, with alphas of .90, .79, and .89 for the inattention, hyperactivity/impulsivity, and ODD subdomains, respectively. The reliability of the teacher ratings was slightly better at .97 for the overall scale, .96 for inattention, .92 for hyperactivity/impulsivity, and .96 for ODD. The report also produced Pearson correlations for the inter-rater reliability between the parent and teacher ratings for each factor. The correlations are as follows: .49 for inattention, .43 for hyperactivity/impulsivity, and .47 for ODD, and all were statistically significant (p < .001)

While the psychometrics of the SNAP-IV may be quite good, it is important to note the limitations of its norms. The researchers may have used sizable samples for their parent (n = 1,613) and teacher (n = 1,205) ratings, as well as for their validation sample (n = 266), but the norms are far more limited. They sampled in just one school district in North Florida with high poverty rates and limited diversity. Additionally, they only included white and African American children in the assessment. Interestingly, there is a Japanese and a Chinese version of the SNAP-IV, each with its own corresponding norms.

There may be valid reasons to take a conservative approach to interpreting the results of the SNAP-IV, but it still functions effectively as a relatively quick and easy screener to use.

References

Bussing, R., Fernandez, M., Harwood, M., Wei, H., Garvan, C. W., Eyberg, S. M., & Swanson, J. M. (2008). Parent and teacher SNAP-IV ratings of attention deficit hyperactivity disorder symptoms: Psychometric properties and normative ratings from a school district sample. Assessment, 15(3),  317-328. doi:10.1177/1073191107313888

Gau, S. S., Lin, C. H., Hu, F. C., Shang, C. Y., Swanson, J. M., Liu, Y. C., & Liu, S. K. (2009). Psychometric properties of the Chinese version of the Swanson, Nolan, and Pelham, Version IV Scale-Teacher Form. Journal of Pediatric Psychology, 34(8), 850-861. doi:10.1093/jpepsy/jsn133

Inoue, Y., Ito, K., Kita, Y., Inagaki, M., Kaga, M., & Swanson, J. M. (2014). Psychometric properties of Japanese version of the Swanson, Nolan, and Pelham, version-IV Scale-Teacher Form: a study of school children in community samples. Brain Development, 36(8), 700-706.          doi:10.1016/j.braindev.2013.09.003