Showing posts with label The ABC. Show all posts
Showing posts with label The ABC. Show all posts

Monday, 16 May 2022

Functioning

 Functioning

The GAS and GAF have been ‘a standard’ to assess global functioning. The social and occupational functioning scale: SOFAS,16 which is a functional derivative of the GAF, has been described only sporadically. They are indeed quite simple and user-friendly but might be too simple to capture functional status. Ongoing efforts in this respect include the personal and social performance scale: PSP29 which modelled the SOFAS, and the functional assessment for comprehensive treatment in schizophrenia: FACT-Sz30 which is similar to the GAF but more detailed and more widely differentiates patients.

 

It has however been infrequent that functional scales, in contrast to symptomatic rating scales, have constituted the primary outcome measure in studies for schizophrenia,31-34 although global functioning appears to serve as a heuristic outcome that may represent ‘the net effect of everything’ in patients. Some studies on child and adolescent schizophrenia used the Children’s version of the GAS.35 On the other hand, global functioning scales specific for geriatric patients have not been reported, which would be all the more pertinent in light of a recent ageing society. However, complexity is how to define a ‘norm (or normal trajectory)’ with which any abnormality or deviance is compared in an aged population (Suzuki et al., submitted).

 

Performance-based scales, such as the UCSD Performance-Based Skills Assessment: UPSA,36 have not gathered much popularity thus far. This might be a result of the unfamiliarity of the performance-based scales despite a claim for their potential usefulness,37 but another important consideration is ‘what patients are actually doing’ versus ‘what patients can potentially do’. Performance-based assessment scales may more closely reflect the latter under a probable impact of cognitive capability, while other aspects such as motivation and mood may be more implicated in the former.38,39

Scales for Adverse Effects

Adverse Effects

This domain mainly consists of two parts—EPS and non-EPS adverse effects. As for the former, the combination of the AIMS (tardive involuntary movement), BARS (akathisia) and SAS (parkinsonism) appear to have been ‘a standard’. The ESRS has been much less commonly used although comprehensive, well presumably due to a lengthy process to complete. This topic has recently been reviewed in detail elsewhere.24 A major challenge here is how to interpret different scales with different item numbers as ‘an overall EPS burden’ within the subject in question. The drug-induced extrapyramidal symptoms scale: DIEPSS25 (nine items) might represent a useful alternative.

 

Non-motor adverse effects, including anticholinergic, metabolic, autonomic and sexual problems, have been usually described without the usage of the scales and sometimes reported in the table, for which standardization is warranted.26 Evaluations that depend on the spontaneous reports may result in underestimation. Although the UKU side effect rating scale has been occasionally used, it still lacks some crucial elements such as metabolic parameters, for which a significant impact in this population is noted27 and regular monitoring is recommended.28 This may be due to the fact that it was published before newer antipsychotic medications, which are relatively more problematic in terms of metabolic disturbances in general, have become widely available in the market.

 

An obvious difficulty for the scales with multiple items is an inherent non-comparability of the same total score for differently endorsed problems (e.g., the possibly non-uniform implication of moderate severity in metabolic versus sexual adverse effects) as well as validity and pragmatic usefulness in severity differentials (e.g., 0–3 (none, mild, moderate, and severe) versus more detailed 0–5 (none, equivocal, mild, moderate, marked and severe)).


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Adapted from Wikipedia. Text is available under the Creative Commons Attribution-ShareAlike License 3.0; additional terms may apply.

Symptoms

Symptoms

The PANSS has been ‘the standard’ scale and is frequently adopted as the primary outcome measure in clinical studies for schizophrenia. It is reasonable to assume the more number of items (and the wider the potential score distribution) in a scale, the more likely one would be able to detect a difference but at the cost of time. In order to discern any difference, it might be better to rate as many scales as possible (e.g., all of the PANSS, BPRS, SAPS, and SANS), which nonetheless would be unrealistically time-consuming and in fact has been a case for none of the 150 studies investigated herein.

 

Redundancy within/across the scales is also of concern. For instance, factor analyses of the PANSS have identified several components19 and as such, rating these extracted factors instead of all 30 items might even be sufficient. In line with this view, efforts are ongoing to make simpler rating scales. For instance, The Clinical Global Impression-Schizophrenia scale: CGI-SCH20 is akin to the CGI but it consists of four common symptomatic aspects (i.e., positive, negative, depressive and cognitive symptoms) in addition to global severity/change. This scale has been used in a series of naturalistic, observational investigations (The European Schizophrenia Outpatient Health Outcomes (SOHO) study).21

 

Affective and anxiety symptoms have not been usually assessed with the rating scale in spite of a relatively high prevalence reported in the literature,22 although it might still be possible to capture these problems with such items as depression, guilt feelings, anxiety, and tension in the PANSS for instance. The Montgomery- ├ůsberg depression rating scale: MADRS23 (10 items) has not been so frequently utilized in this population, and none of the anxiety scales has been commonly used. Another important issue is to evaluate the usefulness of subjective scales for mood and anxiety in patients with schizophrenia.

Discussion

Discussion

It was found that clinical trials in schizophrenia are likely to utilize the PANSS for psychopathology as well as the set of AIMS, BARS and SAS for EPS assessment. Overall frequency in the assessment scales for schizophrenia in an effort to evaluate multiple domains within the illness appeared to be similar across years, except for more recent attention on cognition, functioning and subjective perspectives. The PANSS together with the set of AIMS, BARS and SAS may be regarded as ‘the standard’ in clinical trials for schizophrenia. This ‘standard’ set of assessment scales is expected to take about 60 minutes (30–40/5–10/10/10 minutes for the PANSS/AIMS/BARS/SAS, respectively).2 Such a time requirement obviously represents an obstacle for real-world practice.

 

Studies have utilized different scales for their different interests and we can not be entirely certain about which scales are adequate in a specific study. It is important to acknowledge that all assessment scales do have some pertinence across multiple illness domains. Furthermore, contrary to the naming, the QLS for example was designed to assess deficit symptoms and can well be regarded as a functional outcome measure in schizophrenia. On the other hand, an interpretation of clinical relevance on improvements in a part of the scales, or in subscales within the scale, remains somewhat complex although such a data presentation is sometimes found to focus on statistically significant differences.

 

Limitations of this paper include a limited number of years and studies investigated and an arbitrary classification of outcomes into domains. Outcome measures may be in part guided by the nature of the study (e.g., pharmacologic versus psychosocial) or the setting (e.g., real-world versus research). The year of publication (or tradition) of each rating scale is also an important factor since rating scales would require some time to become familiarized with (and years that accompany the citations serve to have a sense of the ‘age’ of the scales). Challenges with the existing rating scales are discussed below.

Others

Others

In some of the studies, assessments were extended to premorbid adjustment, disability, comorbid substance use, prognostic evaluation, caregivers’ perspectives and aggression and so forth. However, none of the scales has been utilized for ≥10% of the studies in any of the respective years.

Cognition

 Cognition

While some of the cognitive assessments were performed in only 11% in the years 1999 and 2004, they were rated in 30% of the studies in 2009. And the assessments used showed much more variety in 2009, expanding from classical paper-pencil tests to computerized facial emotion recognition tests to multiple tests that are expressed in the context of a composite cognitive score.

Subjective Perspectives

Subjective Perspectives

While some of the studies recorded this domain with the usage of the rating scales, only the quality of life scale: QLS18 (21 items) has been used in 12% of the 2009 studies.

Functioning

Functioning

The global assessment of functioning: GAF16 and its precedent global assessment scale: GAS17 has been the most frequently utilized scale. They simply rate the global status with a score of 0–100. Performance-based functional scales have been very rarely utilized.

Non-Motor Adverse Effects

Non-Motor Adverse Effects

The Udvalg for Kliniske Undersogelser: UKU side effect rating scale15 (48 items plus interference and action items, eight of which evaluate neurologic adverse effects) has been the only scale that was utilized in 13% of the studies in 2004. In 1999, merely one of the 35 studies evaluated non-motor adverse effects with the rating scale (UKU). On the other hand, the frequency of treatment-emergent (motor and non-motor) adverse effects has been occasionally described in tables (spontaneously reported or observed but without the usage of the formal scales).

Extrapyramidal Symptoms

Extrapyramidal Symptoms

It has been typical to assess parkinsonism with the Simpson–Angus scale: SAS11 (10 items), tardive movement disorders with the abnormal involuntary movement scale: AIMS12 (10 items plus two dental status items), akathisia with the Barnes akathisia rating scale: BARS13 (four items). These three scales were frequently rated altogether. In fact, if any one of these scales was assessed, both of the rest were also evaluated in 40% of the cases overall (and as high as 74% in 2009). The extrapyramidal symptom rating scale: ESRS14 (41 items plus 4 CGIs’ for akathisia, dyskinesia, dystonia and parkinsonism) has been used much less frequently.


Copyright Notice

Adapted from Wikipedia. Text is available under the Creative Commons Attribution-ShareAlike License 3.0; additional terms may apply.

Classical Psychopathology (Positive and Negative Symptoms)

Classical Psychopathology (Positive and Negative Symptoms)

As expected, almost all of the studies reported on this aspect with a usage of the rating scales. The PANSS (30-item—7 for positive, 7 for negative and 16 for general psychopathology subscales) has been by far the most frequently utilized scale for this purpose. It was followed by the BPRS (typically 18-item version), which outnumbered the PANSS in 1999, and was sometimes extracted from the PANSS (as 18-item version).

 

The next common scale was the scale for the assessment of negative symptoms: SANS7 (20 symptom items plus five global items) and the scale for the assessment of positive symptoms: SAPS8 (30 symptom items plus four global items). They were rated altogether at times (9 of 150 studies). Sometimes, the SANS was assessed together with the PANSS (8 of 150 studies).

Affective/Anxiety Symptoms

Affective/Anxiety Symptoms

Although the frequency in usage was rather low, the Hamilton rating scale for depression: HRSD9 (typically 17 items), and more recently the Calgary depression rating scale for schizophrenia: CDSS10 (nine items) have been the most frequently recorded scale. In contrast, subjective scales for depression have very rarely been utilized. Rating scales for anxiety symptoms, both objective and subjective, have been barely used.

Global Evaluation

Global Evaluation

The clinical global impression: CGI6 has been the sole scale used as a global measure. It simply evaluates the severity of illness (normal:1 to moderate:4 to most ill:7) as well as change (very much improvement: 1 to no change:4 to very much worsening:7) with a score of 1–7. No other global evaluation scales for severity and change have been utilized.

Home Situations Questionnaire-Pervasive Developmental Disorders version (HSQ-PDD)

Home Situations Questionnaire-Pervasive Developmental Disorders version (HSQ-PDD)

The HSQ-PDD [59] items are scored in two subscales: Socially Inflexible, and Demand-Specific. The properties of the HSQ-PDD were assessed in a sample of 124 children aged 4 to 13 years. Structural validity for a two-factor solution was a reasonable fit (RMSEA 0.06) and internal consistency good (alpha 0.90 for the ‘socially inflexible’ subscale and 0.80 for ‘demand-specific’). Known groups validity and responsiveness (change over time) were also shown as good for the HSQ-PDD by Chowdhury et al [59]. In a further paper, responsiveness was shown related as hypothesised to change in the Vineland Daily Living Skills scale [63].

Child Behavior Checklist 6–18

Child Behavior Checklist 6–18

The CBCL 6–18 [56] was assessed with a sample of ASD youth in two papers [51, 67]. Pandolfi, Magyar and Dill [51] found internal consistency was good with r = 0.92 for the aggressive behaviour scale, but I found no evidence concerning reliability. Structural validity for the complete measure was good and analysis supported the original two-factor structure of the CBCL 6–18 (internalizing and externalising factors). Tests of unidimensionality of scales did not reach the cut off for acceptable fit for aggressive behaviour (RMSEA = 0.10, CFI = 0.95); however, convincing arguments were provided to allow for correlated disturbances in the model for two item pairs (destroys own things/destroys others things and disobedient at home/disobedient at school). This adjusted model showed an acceptable fit (RMSEA<0.06, CFI>0.95). Criterion validity was assessed by Pandolfi, Magyar and Dill [51] by comparing ASD children with and without a co-occurring emotional/behavioural difficulty. Children with a co-occurring EBD scored significantly higher than those without EBDs on total problems, though there were no significant differences between the two groups for aggressive behaviour or externalising behaviour as the most common co-occurring EBDs in the sample were anxiety disorders. Kuhlthau et al [67] hypothesised that externalising behaviours would be more strongly associated with quality of life than internalising behaviours in children with ASD, but this was not supported.

Child Behavior Checklist (CBCL) 1.5–5

Child Behavior Checklist (CBCL) 1.5–5

CBCL 1.5–5 year [5] subscale scores are derived for the following syndromes: Emotionally Reactive, Anxious/Depressed, Somatic Complaints, Withdrawn, Sleep Problems, Attention Problems, and Aggressive Behaviour, and these are further summed to provide scores for Internalizing and Externalizing problems.

 

The CBCL 1.5–5 was assessed by one paper of good methodological quality [72] with a sample of children with ASD. This paper provided evidence of good internal consistency for total problems (Cronbach’s alpha = 0.93) and both the externalizing behaviour domain (Cronbach’s alpha = 0.90) and aggressive behaviour sub-scale (Cronbach’s alpha = 0.80). No evidence was found concerning reliability. Structural validity was also good with an acceptable model fit for a one-factor model for aggressive behaviour (RMSEA<0.06, Comparative Fit Index (CFI)>0.95) indicating that there was a single latent factor underlying this sub-scale.

Behavior Assessment System for Children Second Edition (BASC-2)

Behavior Assessment System for Children Second Edition (BASC-2)

The BASC-2 Parent and Teacher Rating Scale [55] items are organised into 9 clinical subscales: Aggression, Anxiety, Attention problems, Atypicality, Conduct problems, Depression, Hyperactivity, Somatization, and Withdrawal (as well as five adaptive scales). Hass et al. [65] showed that the BASC-2 had acceptable internal consistency for the 10 item aggression scale and the 9 item conduct problem scale with teachers as informants. There were also significant large differences between children with ASD and matched controls on the aggression scale (Cohen’s d = 0.58) and the externalising problems composite scale (Cohen’s d = 0.75). Mahan and Matson [70] also assessed known groups' validity of the BASC-2, with parents as informants. ASD children scored significantly greater than typically developing children on the conduct problems and externalising composite scales, but did not differ as expected on the aggression subscale. No evidence was found on reliability, structural validity or criterion validity for the clinical scales.

 

Baby and Infant Screen for Children with atIsm Traits—Part 3

Baby and Infant Screen for Children with atIsm Traits—Part 3

(BISCUIT-Part 3)

The BISCUIT-Part 3 [58] items are organised into three subscales: Aggressive/Disruptive behaviours, Stereotypic behaviours, and Self-Injurious behaviour. Internal consistency of the BISCUIT-Part 3 was reported as good with Cronbach’s alpha >0.70 in two papers [58, 71] but reliability was not assessed. Structural validity, assessed in Matson, Boisjoli et al [71] was not acceptable, with the exploratory factor analysis resulting in a three-factor solution explaining just 38.32% of the variance.

The ABC

The ABC

Items are scored in five subscales: Irritability, Lethargy/Social Withdrawal, Stereotypic Behavior, Hyperactivity/Non-compliance, and Inappropriate speech. Internal consistency was reported as good by Karabekiroglu and Aman [50] (Cronbach’s alphas from 0.68 to 0.90) and by Kaat, Lecavalier and Aman [66] (alphas from.77 to.94). Inter-rater reliability (between similar raters) and test-retest reliability were not assessed. Brinkley et al. [64] and Kaat, Lecavalier and Aman [66] demonstrated that the ABC had good structural validity; the latter very large study (n = 1893) found that 90% of items matched the standard ABC factor structure, though the model fit was ‘marginal’ (Root Mean Square Error of Approximation (RMSEA) was .086). Sigafoos et al. [73] also showed that the ABC had good structural validity with five factors, though due to the small sample size (n = 32), the Sigafoos paper was judged to be of poor methodological quality. Karabekiroglu and Aman [50] showed that the ABC distinguished between clinical subgroups. Kaat, Lecavalier and Aman [66] found, as expected, that irritability and hyperactivity decreased with age. Kaat, Lecavalier and Aman [66] and Karabekiroglu and Aman [50] found predicted significant correlations with related constructs measured by the Child Behaviour Checklist and the Autism Behaviour Checklist, and Kuhlthau et al. [67] with a measure of child quality of life, the Child Health and Illness Profile—Child Edition.

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