Objectives: The purpose of this study was to analyze the discriminant validity and the clinical cut off scores of the Child Behavior Checklist 1.5-5 (CBCL 1.5-5) in the diagnosis of autism spectrum disorder (ASD) and non-ASD. Methods: In total, 104 ASD and 441 non-ASD infants were included in the st...
Objectives: The purpose of this study was to analyze the discriminant validity and the clinical cut off scores of the Child Behavior Checklist 1.5-5 (CBCL 1.5-5) in the diagnosis of autism spectrum disorder (ASD) and non-ASD. Methods: In total, 104 ASD and 441 non-ASD infants were included in the study. T-test, discriminant analysis, receiver operating characteristic (ROC) curve analysis, and odds ratio analysis were performed on the data. Results: The discriminant validity was confirmed by mean differences and discriminant analysis on the subscales of Emotionally reactive, Somatic complaints, Withdrawn, Sleep problems, Attention problems, Aggressive behavior, Internalizing problems, Externalizing problems, and Total problems, along with the Diagnostic and Statistical Manual of Mental Disorders (DSM)-oriented scales between the two groups. ROC analysis showed that the following subscales significantly separated ASD from normal infants: Emotionally reactive, Somatic complaints, Withdrawn, Sleep problems, Attention problems, Aggressive behavior, Internalizing problems, Externalizing problems, Total problems, and DSM pervasive developmental problems. Moreover, the clinical cut off score criteria adopted in the Korean-CBCL 1.5-5 were shown to be valid for the subscales Withdrawn, Internalizing problems, Externalizing problems, Total problems, and DSM pervasive developmental problems. Conclusion: The subscales of Withdrawn, Internalizing problems, Externalizing problems, Total problems, and DSM pervasive developmental problems significantly discriminated infants with ASD.
Objectives: The purpose of this study was to analyze the discriminant validity and the clinical cut off scores of the Child Behavior Checklist 1.5-5 (CBCL 1.5-5) in the diagnosis of autism spectrum disorder (ASD) and non-ASD. Methods: In total, 104 ASD and 441 non-ASD infants were included in the study. T-test, discriminant analysis, receiver operating characteristic (ROC) curve analysis, and odds ratio analysis were performed on the data. Results: The discriminant validity was confirmed by mean differences and discriminant analysis on the subscales of Emotionally reactive, Somatic complaints, Withdrawn, Sleep problems, Attention problems, Aggressive behavior, Internalizing problems, Externalizing problems, and Total problems, along with the Diagnostic and Statistical Manual of Mental Disorders (DSM)-oriented scales between the two groups. ROC analysis showed that the following subscales significantly separated ASD from normal infants: Emotionally reactive, Somatic complaints, Withdrawn, Sleep problems, Attention problems, Aggressive behavior, Internalizing problems, Externalizing problems, Total problems, and DSM pervasive developmental problems. Moreover, the clinical cut off score criteria adopted in the Korean-CBCL 1.5-5 were shown to be valid for the subscales Withdrawn, Internalizing problems, Externalizing problems, Total problems, and DSM pervasive developmental problems. Conclusion: The subscales of Withdrawn, Internalizing problems, Externalizing problems, Total problems, and DSM pervasive developmental problems significantly discriminated infants with ASD.
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제안 방법
5-5 includes a total of 99 items, and is evaluated on a 3-point scale from 0 to 2 points. Evaluation is based on 7 subscales which are Emotionally reactive, Anxious/depressed, Somatic complaints, Withdrawn, Sleep problems, Attention problems, and Aggressive behavior; 10 syndrome scales including Internalizing problems, Externalizing problems, and Total problems; and 5 scales reflecting the DSM diagnosis system that includes DSM affective problems, DSM anxiety problems, DSM pervasive developmental problems, DSM ADHD, and DSM oppositional defiant problems.
Moreover, stepwise discriminant analysis was performed to analyze which of the subscales can best discriminate between the ASD and non-ASD groups. Discrimination accuracy was shown to be the highest for the DSM pervasive developmental problems, Externalizing problems, Internalizing problems, and Withdrawn subscales, in this order (Table 6).
5-5 subscales in discriminating between ASD and non-ASD using discriminant analysis and ROC analysis. Odds ratio analysis was performed in order to identify clinically meaningful score standards for the measures with confirmed discriminatory power.
The name of the diagnosis was changed from AD in DSMIV to ASD in DSM-5, and the diagnosis criteria expanded, but two characteristics are unchanged; the lifelong character of the symptoms, and the clinically significant impairment they cause in the social and work contexts or in other important areas. A complete cure for development-related disorders including ASD has not yet been reported, but ASD infants who received early diagnosis and treatment interventions showed better prognosis in comparison to ASD infants who did not receive treatment [3-5].
The ROC analysis showed that Emotionally reactive, Somatic complaints, Attention problems, Aggressive behaviors, Sleep problems, DSM affective problems, DSM anxiety problems, DSM ADHD, and DSM oppositional defiant problems can discriminate between ASD and non-ASD group, but did not reach the clinical diagnosis standard cut off, and therefore were excluded from further analysis. Therefore, for the subscales of Withdrawn, Internalizing problems, Externalizing problems, Total problems, and DSM pervasive developmental problems, whose discriminatory power is supported by the ROC analysis, and that are within the clinical diagnosis standard cut off range, odds ratio analysis was performed based on the standard scores (Table 8).
This study analyzed the ability of the subscales in K-CBCL 1.5-5 to discriminate between infant groups diagnosed with ASD and non-ASD. All subscales except the Anxious/ Depressed one, for which discriminatory power was not detected, showed a higher T score for the ASD group than for the non-ASD group.
The specific assessment tool used for ASD diagnosis depends on the institution and there are no specific recommendations on the choice of a specific scale. Thus, a study examined the usefulness of ASD assessment tools [14] by comparing the CBCL 1.5-5 and GARS among autism, ASD, and non spectrum diagnoses according to ADOS. The results showed that the discriminatory power of the Withdrawn and DSM pervasive developmental problems subscales from CBCL 1.
We identified the discriminatory power of the K-CBCL 1.5-5 subscales in discriminating between ASD and non-ASD using discriminant analysis and ROC analysis. Odds ratio analysis was performed in order to identify clinically meaningful score standards for the measures with confirmed discriminatory power.
We were thus able to suggest the criteria for discriminating the ASD group at the most appropriate level, based on the sensitivity and specificity revealed by the ROC analysis. We also conducted an analysis of odds ratios, centered at the base point, which can serve as a guideline to understand and use the subscale scores after establishing their discriminatory power.
대상 데이터
A total of 545 infants (415 males and 130 females) who came into the Pediatric Psychiatric Department of the General Hospital, the Rehabilitation Medicine Center, the Delayed Development Clinic, or the Development Center in Seoul and the Gyeonggi Province and received a diagnosis of disorder after a professional medical interview and general psychological evaluation, between July 2008 and June 2015, were enrolled this study (IRB No. SMWU-1505-HR-010). The distribution of the age and gender of the subjects are detailed in Table 1.
데이터처리
, Armonk, NY, USA). A t-test was conducted to identify the differences between ASD and non-ASD groups for each item in the subscales of K-CBCL 1.5-5. To investigate how accurate the discrimination between the two groups can be, discriminant analysis was performed.
Second, the study of the discriminatory power of the KCBCL 1.5-5 using discriminant analysis showed that effective discrimination occurred using subscales with high T scores in the ASD group compared to the non-ASD group, as shown by t-tests. When discriminant analysis was performed using syndrome scales, excluding Anxious/Depressed, and DSM diagnosis subscales simultaneously, the classification accuracy in discriminating the ASD group was found to be 73.
성능/효과
Comparison of the K-CBCL 1.5-5 subscales between ASD group and non-ASD group showed that the ASD group scored significantly higher than the non-ASD group in all subscales, except for the Anxious/Depressed one (Table 3).
For DSM pervasive developmental problems, the odds ratio at the borderline level of 65T was 0.11, and the ASD group classification rate was 31.5%, while odds ratio at the clinical diagnosis level of 70T was 0.12, and the ASD group classification rate was 39.2%.
For Internalizing problems, the odds ratio at the borderline level of 60T was 0.34, and the ASD group classification rate was 30%, while the odds ratio at the clinical diagnosis level of 64T was 0.40. For Externalizing problems, the odds ratio at the borderline level of 60T was 0.
47. For Total problems, the odds ratio at the borderline level of 60T was 0.40, and the ASD group classification rate was 27.7%, while the odds ratio at the clinical diagnosis level of 64T was 0.48.
For Withdrawn, the odds ratio at the borderline level of 65T was 0.19, and the ASD group classification rate was 30.9%, while at the clinical diagnosis level of 70T the odds ratio was 0.17 and the ASD group classification rate was 42.6%.
Fourth, the subscales identified to best discriminate between ASD and non-ASD group were analyzed in terms of the cut off suggested in the normalization standards, and all were shown to be usable based on the standards. The sensitivity and accuracy were the highest when the borderline level of 65T was used for the Withdrawn scale, and 70T for the DSM pervasive developmental problems.
These results are in conflict with results from an ASD group compared to a normal group [15], which showed the highest discriminatory power for DSM pervasive developmental problems, Internalizing problems, and Attention problems. Our results also differ from those of a study which identified the power of subscales to discriminate between the diagnosed clinical group and the normal group [19] and found that classification accuracy of the DSM pervasive developmental problems, Attention problems, DSM ADHD, and Internalizing problems subscales were the highest. Moreover, our results are different from those of a study which analyzed the power of the subscales to discriminate between the clinical group diagnosed with delayed development and the normal group[16], and found that the discriminatory powers of Withdrawn, Attention problems, Internalizing problems, Total problems, and DSM pervasive developmental problems were the highest.
For Internalizing problems, Externalizing problems, and Total problems the standard borderline cut off standard is 60T, and the one for clinical diagnosis is 64T. The ROC analysis showed that Emotionally reactive, Somatic complaints, Attention problems, Aggressive behaviors, Sleep problems, DSM affective problems, DSM anxiety problems, DSM ADHD, and DSM oppositional defiant problems can discriminate between ASD and non-ASD group, but did not reach the clinical diagnosis standard cut off, and therefore were excluded from further analysis. Therefore, for the subscales of Withdrawn, Internalizing problems, Externalizing problems, Total problems, and DSM pervasive developmental problems, whose discriminatory power is supported by the ROC analysis, and that are within the clinical diagnosis standard cut off range, odds ratio analysis was performed based on the standard scores (Table 8).
5-5 and GARS among autism, ASD, and non spectrum diagnoses according to ADOS. The results showed that the discriminatory power of the Withdrawn and DSM pervasive developmental problems subscales from CBCL 1.5-5 were greater compared to the CARS autism scale. Moreover, a study of normal and ASD groups based on the CBCL 1.
Moreover, another study which analyzed the discriminatory power of subscales between the ASD and the normal group [15] found that the Withdrawn, Attention problems, Internalizing problems, Externalizing problems, Total problems, DSM pervasive developmental problems, DSM ADHD, and DSM oppositional defiant problems scales had discriminatory power. Therefore, the adequacy of the DSM pervasive developmental problems and Withdrawn scales in discriminating the ASD group was confirmed.
Third, our analysis of the power of subscales to discriminate between ASD and non-ASD group using ROC analysis shows that the discriminatory power of DSM pervasive developmental problems is excellent, the one of Withdrawn is adequate, and that of Aggressive behaviors, Internalizing problems, Externalizing problems, DSM ADHD, and DSM oppositional defiant problems is at the level of support. A study that analyzed the discriminatory power of subscales between the clinically diagnosed and the normal group [19] showed that all subscales except Somatic complaints and Sleep problems had discriminatory power.
5-5 using discriminant analysis showed that effective discrimination occurred using subscales with high T scores in the ASD group compared to the non-ASD group, as shown by t-tests. When discriminant analysis was performed using syndrome scales, excluding Anxious/Depressed, and DSM diagnosis subscales simultaneously, the classification accuracy in discriminating the ASD group was found to be 73.9%.
후속연구
Therefore, we suggest a future study controlling for the non-diagnosis and multiple-diagnoses cases. Moreover, while our study showed that the Withdrawn and DSM pervasive developmental problems scales of K-CBCL 1.5-5 can well discriminate ASD from non-ASD, the reality is that using K-CBCL 1.5-5 as the only measure to diagnose ASD is difficult, and needs confirmatory future research. However, features of the Withdrawn scale such as “Avoids looking into another person’s eyes” and “Does not answer when talked to by people” and those of the DSM pervasive developmental problems such as “Does not play well with other children” and “Repetitively shakes head or body” are constructed in the same vein as the items “Persistent deficits in social communication and social interaction across multiple contexts” and “Tendency for restricted, repetitive pat- terns of behavior, interests, or activities” included in the ASD diagnosis criteria in DSM-5.
These results show a difference between the ASD and non-ASD groups, albeit at a level below the standard score, which can be seen as a level comparable to the normal group which does not show behavioral problems. Therefore, also these considerations suggest a comparison among three groups-normal, ASD, and non-ASD-to be needed as a follow-up study.
non-ASD, the classification rate that can misclassify non-ASD as ASD was lower than that found in previous studies [20]. This can result in higher rates of misdiagnosing non-ASD as ASD, and therefore a follow-up study comparing the normal, ASD, and non-ASD groups is needed.
참고문헌 (20)
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