16 May For this assignment, select a construct you may want to use in your future dissertation (e.g. aggression, burnout, social anxiety, emotional intelligence).? Find two dif
•For this assignment, select a construct you may want to use in your future dissertation (e.g. aggression, burnout, social anxiety, emotional intelligence).
•Find two different measurements that measure this construct. Include an overview of each measurement- what do they measure and how (scale information).
•How are the tests similar/different? What may be the advantages of using one test over another?
•Report reliability (numbers) for each scale based on research (provide citations)
•Length: 1-2 pages
•Include APA style cover page, headings, citations & references
An Icelandic version of the Kiddie-SADS-PL: Translation, cross-cultural adaptation and inter-rater reliability
´ BERTRAND LAUTH, PA ´ LL MAGNU ´ SSON, PIERRE FERRARI, HANNES PETURSSON
Lauth B, Magnússon P, Ferrari P, Pétursson H. An Icelandic version of the Kiddie-SADS-PL: Translation, cross-cultural adaptation and inter-rater reliability. Nord J Psychiatry 2008;62: 379�385. Oslo. ISSN 0803-9488.
The development of structured diagnostic instruments has been an important step for research in child and adolescent psychiatry, but the adequacy of a diagnostic instrument in a given culture does not guarantee its reliability or validity in another population. The objective of the study was to describe the process of cross-cultural adaptation into Icelandic of the Schedule for Affective Disorders and Schizophrenia for School-Age Children*Present and Lifetime Version (Kiddie-SADS-PL) and to test the inter-rater reliability of the adapted version. To attain cross- cultural equivalency, five important dimensions were addressed: semantic, technical, content, criterion and conceptual. The adapted Icelandic version was introduced into an inpatient clinical setting, and inter-rater reliability was estimated both at the symptom and diagnoses level, for the most frequent diagnostic categories in both international diagnostic classification systems (DSM-IV and ICD-10). The cross-cultural adaptation has provided an Icelandic version allowing similar understanding among different raters and has achieved acceptable cross- cultural equivalence. This initial study confirmed the quality of the translation and adaptation of Kiddie-SADS-PL and constitutes the first step of a larger validation study of the Icelandic version of the instrument. � Child psychiatric interview, Diagnostic instruments, Inter-rater reliability, K-SADS-PL, Translation and cross-cultural adaptation.
Bertrand Lauth, University of Iceland, Landspitali University Hospital, Department of Child and Adolescent Psychiatry, Dalbraut 12, 105 Reykjavı́k, Iceland, E-mail: [email protected] is; Accepted 20 September 2007.
T he development of structured diagnostic instruments
has been an important step for research in child and
adolescent psychiatry. These standardized instruments
are based on the more descriptive taxonomy of recent
editions of international classification systems, DSM-IV
(1) and ICD-10 (2). They are essential for research and
are good aids for clinicians, since they provide a
structured and systematic assessment procedure that
has increased diagnostic reliability.
However, for researchers belonging to cultural back-
grounds and speaking languages other than English, the
adoption of such an instrument involves a process of
translation and adaptation of the instrument. The
adequacy of the diagnostic instrument in a given culture
does not guarantee its reliability or validity in another
population (3). The challenge for these researchers is then
to develop a translated and adapted version of the
assessment tool, which is equivalent to the original
version of the instrument. Only by achieving this equiva-
lence will it be possible to assure the degree of compar-
ability in studies carried out in different cultures (3).
The need for diagnostic instruments has led the
authors to start the development of a local version of
the Kiddie-SADS-PL for research in clinical populations.
Because of the lack of European consensus statement
about standard and validated practices on that topic, we
started with a classic translation/back-translation process
to try to achieve semantic equivalence and then started to
introduce the structured interview into an adolescent
inpatient clinical setting.
The impact of the introduction of the diagnostic
instrument is described in another publication, as well
as additional studies on the psychometric properties of
the Icelandic version in an adolescent clinical population.
# 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As) DOI: 10.1080/08039480801984214
B LAUTH ET AL.
This article describes the process of translation and
adaptation of the instrument as well as inter-rater reliability data.
The importance of structured psychiatric interviews in child and adolescent psychiatry Research does not support unstructured interviews as
reliable means to standardized diagnoses (4). Even experienced clinical interviewers are not reliable diag-
nosticians when compared which each other or when
compared with structured interviews (5�8). Agreement is
usually low in studies involving outpatients or hospita-
lized children and adolescents (5, 6, 9�12). Agreement is
usually higher for externalizing disorders than for inter-
nalizing and many authors suggest that diagnoses of
anxiety and depression are often missed using an unstructured interview. Miller (7, 8) has suggested that
because the structured interview yields precise diagnostic
data, appropriate treatments may be delivered earlier,
leading to more rapid recovery and shorter hospital stays.
Research is still needed to establish the utility of
diagnostic interviews in clinical settings, but by encoura-
ging clinicians to follow standard diagnostic and inter-
viewing methods, they promote more consistent diagnostic practices and help justify therapeutic inter-
ventions and outcomes. However, the instruments are
not a substitute for clinical judgement. As McClellan &
Werry (13) pointed out, psychiatric decision making
depends on the integration of information from diverse
sources and perspectives, including the patient and
family interviews, the mental status examination, collat-
eral informants (teachers) and other treatment providers. The pre-eminent role of the clinician must be recognized
Choice of a ‘‘state of the art’’ psychiatric diagnostic interview In this project, an interviewer-based diagnostic interview that requires some clinical decision making on the part
of the interviewer was chosen. This kind of instrument is
often used in studies of clinical populations and is
preferred by clinicians to respondent-based interviews
(13), even though it usually shows poorer reliability.
The ‘‘Kiddie-Schedule for Affective Disorders and
Schizophrenia for School-Age Children’’ (‘‘K-SADS’’)
has changed since its original publication (14) and is currently available in different DSM-IV format versions:
the Kiddie-SADS-P IVR (Present State), the Kiddie-
SADS-L (Lifetime), the Kiddie-SADS-PL (Present and
Lifetime Version) and the Kiddie-SADS-E (Epidemio-
logical) (15, 16).
The ‘‘Present and Lifetime’’ version (K-SADS-PL)
has several strengths (16). It has strong content validity
because it was designed to tap pre-specified diagnostic criteria. It has been designed to lead the clinician or the
therapist to make DSM-IV diagnoses during interviews
of the young patient and his parent, including detailed probes useful in eliciting clinically meaningful informa-
tion. One strength of the Kiddie-SADS-PL is its high
degree of precision and detail in assessing child symp-
toms and their onset, severity, duration and associated
impairments. It is the only instrument that provides
global and diagnosis-specific impairment ratings to
facilitate the determination of ‘‘caseness’’ (17). The
Kiddie-SADS-PL provides also a clinician-friendly front and screening examination, which may result in a more
efficient shorter interview. Skip-decisions seem reliable
and have been validated by comparison with other
symptom measures (18).
In comparison to other child diagnostic instruments,
the K-SADS-PL compares favourably with test�retest
reliability estimates (17) and adequate concurrent valid-
ity of the K-SADS-PL diagnoses was established against several standard self-report scales (18). Its strength
remains in diagnoses of affective and anxiety disorders;
it has also been demonstrated to have good reliability for
Use of the Kiddie-SADS-PL requires extensive clin-
ical experience and instrument specific training. Diag-
nostic algorithms have not been computerized, so
diagnoses are formulated by expert judgement.
Translation and adaptation of Kiddie-SADS-PL We followed the cross-cultural adaptation model used to
translate into Spanish and culturally adapt the Diag- nostic Interview Schedule for Children (DISC) (19).
Even if cultural differences between American and
Icelandic children and adolescents may be to some
extent less important than between American and
Spanish-speaking child and adolescent populations, we
aimed at attaining cross-cultural equivalency by addres-
sing five important dimensions: semantic, technical,
content, criterion and conceptual. This model provided the frame of reference employed
in the development of an Icelandic version of the K-
It involves the choice of terms and sentence structures
that ensure that the meaning of the source language
items is preserved in the translation. Semantic equiva- lence can be achieved with a combination of translation
and back-translation techniques (20).
In our case, two different translaters have indepen-
dently translated and back-translated the instrument.
Following Geisinger’s recommendations (21), they are
fluent in both languages, knowledgeable about both
cultures and have a good understanding of clinical
characteristics and content that the instrument is supposed to evaluate. Translation and back-translation
NORD J PSYCHIATRY �VOL 62 �NO 5 �2008 380
AN ICELANDIC VERSION OF THE KIDDIE-SADS-PL
drafts have been examined by a bilingual committee
composed of the two translaters and four bilingual and
experienced clinicians in child and adolescent psychiatry.
Feedback from interviewers after initial field testing was
essential in further improving the translation.
A few examples of differences between original and
back-translated instruments are following, illustrating
some of the semantic problems that had to be solved:
. Sadness/depressed mood;
. Separation from/absence of the mother;
. Racing/quick thoughts;
. Diurnal mood variations/daily mood fluctuations;
One difficulty consisted in that the English vocabulary is
broader and more detailed than the Icelandic one, which
in particular includes fewer words to describe emotions
The purpose here is to examine whether the content of
each item is meaningful to the population under study
and, if necessary, to remove some of them. In the
Icelandic version of Kiddie-SADS, we had for example
to remove ‘‘Walking on the train tracks’’, since transport
by train does not exist in Iceland. Additionally we had to
remove some references to famous US teenagers’ gangs,
as well as several examples of social games common with
American children and replace them by equivalent
Another issue in the field of content equivalence is to
determine whether the operationalization of what con-
stitutes normal behaviour is relevant to the culture under
study, with special consideration to evaluation of im-
pairment and social adaptation (normative equivalence).
Since Kiddie-SADS items include systematic estimation
of impairment or social adaptation, those issues have
been carefully examined by our bilingual committee.
The issues addressed in this field are related to under- or
over-reporting of certain problems by some cultural
groups compared to others (substance abuse, sexual
behaviour and thoughts, certain feelings). We considered
here the openness with which particular topics are
discussed by Icelandic teenagers, the manner in which
ideas are expressed and the way in which strangers
asking questions are treated. The most significant
particularity we described (but not systematically as-
sessed) was related to difficulties, showed in our
experience by many Icelandic boys, to express both
positive and negative emotions, especially anxiety.
This refers to the fact that the same theoretical construct
should be evaluated by the two versions of the assessment
instrument in the different cultures involved. Does the
concept operationalized in the source instrument (in-
dependently of the words and phrases used to represent
it) exist in the same form in the thinking of members of
the target culture?
In our case, two important discrepancies revealed by
differences between original and back-translated ver-
sions illustrated conceptual problems:
. Conduct/behavioural disorder;
. Attachment figure/someone close
The concept of attachment as it exists in English
semiology is almost impossible to translate into Icelandic.
Behling & Law (22) pointed out that translation/back-
translation was not an adequate test of the equivalence
of the target and source-language documents, but deals
only with semantic equivalence. The two versions may
correspond with one another for the wrong reasons and
target-language version may still not convey the in-
tended meaning to potential respondents.
Solving conceptual problems needs careful considera-
tion of: the constitutive definition of the concept of
interest, the theory that explains it and the nature of any
difference between the source and the target culture.
Usually this kind of equivalence cannot be directly
assessed except for rating scales with a known factorial
structure, which could be empirically tested with a
confirmatory factor analysis, trying to find the same
factor structure in the translated version.
Solving problems in that field involves identifying
pertinent norms in each culture and assessing when the
trait or disorder evaluated is said to exist according to
these norms. In our case, the culture for which Kiddie-
SADS is to be adapted is not very different from the
culture for which the instrument was developed and we
were not able to identify significant symptoms of mental
distress that would appear different culturally from those
included in the original version of the instrument.
However, we were aware of cultural differences in how
parents and professionals view behavioural problems.
In this study, we were not able to validate the
instrument against best estimate clinical judgement
from various Icelandic child and adolescent psychia-
trists, so we designed a study of the concurrent validity
using 11 well-known checklists and rating scales,
which had already been translated and validated in
Iceland and that assess several important dimensions of
psychopathology. This validation study will be the
subject of a separate paper.
NORD J PSYCHIATRY �VOL 62 �NO 5 �2008 381
� � �
B LAUTH ET AL.
Methods Clinical context The adolescent unit of the Department of Child and Adolescent Psychiatry of the Landspı́tali University
Hospital in Reykjavı́k, is the only psychiatric ward for
adolescents in Iceland, admitting each year between 70
and 80 patients from 11 to 18 years of age, from all parts
of the country. The main reasons for admission are
severe behavioural or emotional disturbances with severe
functional impairment and often suicidality (61% of
cases in the period 2001�2004), 53% being acute admis- sions. Mean length of stay was 43 days (2001�2004).
Adolescents presenting with alcohol and drug abuse as a
predominant problem are referred to other service
providers, such as social services. The population
admitted is culturally homogeneous and its geographic
distribution throughout the country is representative of
the general population for the same age categories.
Since the unit is the only facility in the country providing psychiatric inpatient treatment for adoles-
cents, we assume that our population is representative
of the most severe range of psychiatric morbidity of the
adolescent clinical population in Iceland.
Participants Fifteen subjects were included in the inter-rater relia-
bility data pool; the mean age was 15.2 (standard
deviation, s 1.0, range 14�17), 55% being females and all were Icelandic.
These subjects were chosen at random among parti-
cipants in the validation study (n 86, mean age
15.0 years; s 1.34; range 11�18), females accounted
for 55.7% and again, all were Icelandic. They were
severely affected in most of the cases and some of them
could not complete the diagnostic interview.
Measures As the main official diagnostic classification system in
European countries is ICD-10 for both clinical and
research purposes, results of Kiddie-SADS interviews
algorithms have been translated into the ICD-10. A few
additional questions were included in the interviews for
ICD-10 criteria not covered by the K-SADS-PL.
Both DSM-IV and ICD-10 diagnoses were generated,
and numbers of diagnostic criteria met were calculated for the most frequent diagnostic categories in both
Two coders checked to verify accurate utilization of
DSM-IV and ICD-10 algorithms in the calculation of
numbers of diagnostic criteria met and assignment of
Procedure Inter-rater reliability was estimated with 15 interviews being re-rated independently by other experienced and
trained clinicians. Three clinical psychologists and one
child and adolescent psychiatrist took part in the project. Interviews were either videotaped or attended
at the same time by another rater.
Statistical analysis The Statistical Package for Social Sciences was used for
data analysis (23). For comparisons of categorical
variables, chi-square tests were applied. Cohen’s Kappa
(24) was used for reliability measures. Criteria proposed
by Landis & Koch (24) were used to interpret the Kappa
coefficients: excellent reliability (Kappa 0.75), good
reliability (Kappa 0.59�0.75), fair reliability (Kappa 0.40�0.58) and poor reliability (KappaB0.40).
Kappa values were calculated in both classification
systems and for most frequent diagnostic categories. In
each diagnostic area, inter-rater reliability was also
examined at the symptom level, with Kappa values
calculated for each item. Correlations between numbers
of diagnostic criteria met generated by different K-
SADS raters were calculated. Inter-rater reliability was also examined for main
diagnostic areas surveyed in the screen interview, in order
to estimate agreement in utilization of skip-out criteria.
Since several severely affected patients could not
complete the diagnostic interview, the number of sub-
jects allowing calculation of inter-rater reliability varied
according to diagnostic categories.
Results Inter-rater reliability of skip-out criteria The average agreement evaluated by calculation of
Kappa statistics across the nine diagnostic categories
studied here is fair to excellent (Table 1).
Inter-rater reliability of diagnosis assignment Kappas for diagnoses ranged from 0.31 to 1.0 (Table 2).
In each diagnostic category, inter-rater reliability was
also examined at the symptom level with Kappas
calculated for each item. Table 3 summarizes the results
Table 1. Inter-rater reliability: Agreement in utilization of skip-out criteria.
Diagnostic area in screen interview Kappa value n
Depressive disorders 1.00 15
Bipolar disorders 0.86 14
Attention-deficit/hyperactivity disorder 1.00 11
Oppositional defiant disorder 1.00 12
Conduct disorder 0.67 12
Post-traumatic stress disorder 1.00 8
Social phobia 1.00 12
Separation anxiety disorder 0.81 12
Generalized anxiety disorder 0.57 12
NORD J PSYCHIATRY �VOL 62 �NO 5 �2008 382
Table 2. Inter-rater reliability: measure of agreement on diagnoses.
Diagnostic category Kappa value n
Major depressive disorder (DSM-IV) 1.00 15
Melancholic depression (DSM-IV) 0.55 15
Dysthymia (ICD-10) 0.63 15
Moderate depressive episode (ICD-10) 0.32 15
Severe depressive episode (ICD-10) 0.44 15
Somatic syndrome (ICD-10) 0.47 15
Mania (DSM-IV) 0.31 14
Hypomania (DSM-IV) 1.00 14
Bipolar disorder not otherwise 0.44 14
Mania (ICD-10) 0.44 14
Hypomania (ICD-10) 1.00 14
ADHD*predominantly inattentive 0.81 11
ADHD*predominantly 1.00 11
hyperactive-impulsive type (DSM-IV)
ADHD*combined type 1.00 11
(DSM-IV)/hyperkinetic disorder (ICD-10)
Oppositional defiant disorder (DSM-IV) 1.00 12
Oppositional defiant disorder (ICD-10) 1.00 12
Conduct disorder (DSM-IV and ICD-10) 1.00 12
Post-traumatic stress disorder (DSM-IV) 0.67 6
Post-traumatic stress 0.57 6
disorder*chronic type (DSM-IV)
Post-traumatic stress disorder (ICD-10) 0.67 6
Social phobia (DSM-IV) 0.82 12
Social anxiety disorder of 1.00 12
Separation anxiety disorder (DSM-IV) 1.00 12
Separation anxiety disorder of 1.00 12
Overanxious/generalized anxiety 1.00 12
Overanxious/generalized anxiety 0.82 12
ADHD, Attention-Deficit/Hyperactivity Disorder.
with average values calculated within each diagnostic
The inter-rater reliability data pool allowed calcula-
tion of correlations between numbers of diagnostic criteria met generated by different K-SADS raters and
calculated in main areas of psychopathology, related to
both classification diagnostic systems. Statistically sig-
nificant correlations between different raters’ severity
scores were found at the 0.01 level in all diagnostic
categories (Table 4).
Discussion The translation and adaptation process of the Kiddie-
SADS-PL into the Icelandic language and culture aimed
at attaining cross-cultural equivalency by addressing five
important dimensions: semantic, technical, content,
criterion and conceptual.
The results of the study on inter-rater reliability must be interpreted cautiously given the small size of the
AN ICELANDIC VERSION OF THE KIDDIE-SADS-PL
Table 3. Inter-rater reliability: average values at the symptom level within each diagnostic category.
Diagnostic category Kappa value n
Depressive disorders 0.83 15
Bipolar disorders 0.85 14
ADHD*inattention 0.90 11
ADHD*hyperactivity-impulsivity 0.94 11
Oppositional defiant disorder 0.98 12
Conduct disorder 0.96 12
Post-traumatic stress disorder*current 0.93 9
Post-traumatic stress disorder*msp 0.86 3
Social phobia 0.48 12
Separation anxiety disorder 0.78 12
Generalized anxiety disorder 0.82 12
ADHD, Attention-Deficit/Hyperactivity Disorder msp, most severe
research sample. Additionally, two different measuring
procedures were used: in-session observation and video-
The data collected in this study were, however, in line
with those reported by other investigators (4, 12, 18, 25� 27). Agreement in utilization of skip-out criteria was
excellent for most diagnostic categories but moderate for
generalized anxiety disorder. Agreement in the assign-
ment of most frequent diagnostic categories was ex-
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