Prudence Fisher, MS, CSW and Helene Jackson, Ph.D.
The comprehensive and systematic assessment of symptoms is an essential part of any clinical evaluation of children and adolescents. Although reliable and valid standardized diagnostic instruments have been developed, in most clinical out patient services such measures are rarely part of the evaluation process. The use of the unstructured clinical interview has many drawbacks (Kendell, 1975), including its variable structure and limited information upon which to base a diagnosis. The clinician's tendency to focus on data that will confirm a diagnosis, ignore con flicting evidence (Simon et al., 1971; Elstein et al., 1972; Kendell, 1973), and frequently overlook rare or socially embarrassing items (Greist et al., 1973; Bec1: et al., 1988; Levine et al., 1989; Lucas et al., 1977; Bagley & Genius, 1991) is a serious concern.
Personal characteristics of the clinician Jackson & Nuttall, 1993; Jackson &r Nuttall, 1994) and the nonclinical characteristics of a patient, such as race, gender and age, can affect how clinicians conduct a clinical inter view, leading them to focus on certain issues or, more importantly to avoid others (Gauron & Dickinson, 1966b; Burgoyne, 1977; Jackson & Nuttall, 1994). Clinicians often have very little idea of the "true" probabilities of symptom-disease relationships (Gauron & Dickinson, 1966a; Leaper et al., 1972). The advent of frequently changing criterion-based diagnostic systems, such as the DSM-III (APA, 1980), DSM-111-R (APA, 1987) and DSM-IV (APA, 1994) and ICD-10 (WHO, 1993), may also have introduced new sources of clinical unreliability It is not surprising then that even the most able and diligent clinicians find it extremely challenging to organize and retain diagnostic logic, eliminate bias, and use diagnostic labels in the way they were intended.
Research studies show that many of these problems have been obviated by the use of standardized interviewing techniques. Epidemiological research in particular uses reliable measures that can be given to a large number of subjects at low cost. These benefits are consistent with the needs of under staffed clinical services for children and adolescents. Other research has explored whether a combination of a comprehensive automated assessment of symptomatology with a subsequent sensitive exploration of presenting complaints by a clinician might represent an optimal approach (Williams et al., 1975; Farrell et al., 1987; Yokley Reuter, 1989; Sawyers et al., 1992).
Although these findings are products of uncontrolled naturalistic studies, they strongly support the notion that when made avail able to clinicians, computer-generated reports can inform and guide diagnostic impressions and decisions.
More research is needed to better under stand the implications of using this procedure. The need is therefore urgent to address scientifically the impact of the introduction and use of such standardized assessment procedures on clinical services using appropriate controls and design safeguards. This need led to the current study
The Current Study: The CDISC in Clinical Services
This three-year NlMH-funded study examines the impact of introducing a standardized assessment procedure, the NIMH DISC, on clinical practice in community-based child mental health. It is funded with a budget of approximately one million dollars.
The DISC is a highly structured diagnostic interview designed to be administered by lay interviewers to assess most of the commonly occurring mental disorders of children and adolescents included in the DSM diagnostic system (APA, 1994). Parallel parent and child versions of the instrument exist, the DISC- P (parent self-report about their child, age 6 to 17) and the DISC-C (child self-report about himself, age 9 to 17 ). The DISC is probably the most extensively tested of all the child and adolescent diagnostic interviews. Its performance has been evaluated using both clinical and community samples (Shaffer, et al., submitted; Schwab-Stone et al., submitted; Jensen et al., in press; Fisher et al., 1993).
Questions for the current study include: Is the DISC a useful tool in clinical settings? Is important information discovered by the DISC? Do clinicians find the DISC reports helpful in their evaluation of new intakes? Does clinical practice change if the DISC is used? How do clients/parents feel about the use of the DISC in their intake assessments? Does the CDISC save time? Is use of lay interviewers economical?
The study is being conducted in collaboration (and under subcontracts) among the New York State Psychiatric Institute, the Center for the Study of Social Work Practice and the University of Medicine and Dentistry of New Jersey (UMDNJ) at Newark. English-speaking children aged 9 to 18, and their parents, who come for an initial evaluation at the JBFCS Madeleine Borg Community Services and the UMDNJ Community Mental Health Center, and their intake cliniciansó 800 parent/caretaker-child pairs and 80 cliniciansóare expected to participate. The study will use a repeated-measures, matched-group design in which secular trends and seasonal changes in diagnoses will be controlled to examine the impact of the CDISC on clinicians' diagnostic and clinical practice, and on patient satisfaction.
Lay interviewers will administer the CDISC, a computerized user-friendly version of the DISC, to child and parent/caretaker participants. The CDISC corresponds exactly to the official paper version of the interview, but has the following advantages: it simplifies administration; it has database properties; and, most importantly, it can produce diagnostic reports immediately at completion of the interview.
Diagnosing clinicians will be provided reports from the CDISC prior to their first interview. During the first 12-month period of the project, the original subject group,
Group A, will receive the CDISC and a contrast group, Group B, will be observed and recorded. Dunug a second 12-month period, Group B will receive the CDISC and Group A will be observed and recorded.
With increasing pressure on clinical services, it is expected that a diagnostic tool such as the CDISC will help focus scarce resources quickly, more cost- effectively and with greater accuracy to children and adolescents in need of mental health intervention. Objective and quantifiable baseline measures also will provide a basis for evaluating treatment effects and lead to expert systems that will allow evaluators to determine the appropriateness of given interventions.
New York State Psychiatric Institute: Principal Investigator: David Shaffer, MD Co-lnvestigators: Prudence Fisher, MS, CSW and Christopher Lucas, MD Center for the Study of Social Work Practice: Principal Investigator: Ed Mullen, DSW (CUSSW) Co-lnvestigators: Bruce Grellong, PhD OBFCS); Robert Abramovitz, MD OBFCS) and Helene Jackson, PhD (CUSSW)
1. APA (1980). DSM 111 Diagnostic and Statistical Manual, 3rd Edition. American Psychiatric
Association: Washington, D C.
2. APA (1987). DSM III-R Diagnostic and Statistical Manual, 3rd Edition Revised. American
Psychiatric Association: Washington, D.C.
3. APA (1994). DSM IV Diagnostic and Statistical - Manual, 4th Edition. American Psychiatric
Association: Washington, D.C.
4. Bagley C., Genius, M. (1991). Psychology of computer use: XX. Sexual abuse recalled: evaluation of a computerized questionnaire in a population of young adult males. Perceptual and Motor Skills, 72, 287-288.
5. Beck, A. T, Steer, R. A, Ranieri, W E: (1988). Scale for suicidal ideation: psychometric properties of a self report version. J Clin Psychol, 44, 499-505.
6. Burgoyne, R.W (1977). The structured interview- an aid to compiling a clear and concise database. International Mental Health, 6, 37- 48.
7. Elstein, A. S., Kagan, N., Shulman, L. S., Hilliard, J., &r Loupe, M. J. (1972). Methods and theory in the study of medical inquiry. J Med Education, 47, 85-92.
8. Farrell, A. D., Camplair, P S. & McCullough, L. (1987). Identification of target complaints by computer interview: Evaluation of a computerized assessment system for psychotherapy evaluation and research. J Consult Clin Psychol, 55, 691-700.
9. Fisher, P, Shaffer, D., Piacentini, J. C., Lapkin, J., Kafantaris, V, Leonard, H., Herzog, D. B. (1993). Sensitivity of the Diagnostic Interview Schedule for Children, 2nd edition (DISC 2.1) for specific diagnoses of children and adolescents. J Am Acad Child Adolesc Psychiatry, 32, 666-673.
10. Fisher, P, Blouin, A., Shaffer, D. (1993b). The C-DISC: A computerized version of the NIMH Diagnostic Interview Schedule for Children, Version 2.3. Poster Presentation at SRCAP, Santa Fe, New Mexico.
11. Gauron, E.F, Dickinson,J.K. (1966a). Diagnostic decision making in psychiatry. ll. Diagnostic styles. Arch Gen Psychiatry, 14, 233-237.
12. Gauron, E.F, Dickinson, J.K.
(1966b). Diagnostic decision making in psychiatry 1. Information usage. Arch Gen Psychiatry, 14, 225-232.
13. Greist, J. H., Gustafson, D. H., Stauss, F F, Rowse, G. L., Laughren, T P, Chiles, J. A. (1973) A computer interview for suicide risk prediction. Am J Psychiatry, 130, 1327-1332.
14. Jackson, H. & Nuttall, R. (1994). Effects of gender, age and a history of abuse on social workers' judgments of sexual abuse allegations. Social Work Research, 18, (2), 65-128.
15.Jackson, H. & Nuttall, R. (1993). Clinician responses to sexual abuse allegations. Child Abuse & Neglect, 17, 127-143.
16. Jensen, P, Roper, M., Fisher, P, Piacentini, J., Canino, G., Richters, J., Rubio-Stipec, M., Dulcan, M., Goodman, S., Davies, M., Rae, D., Shaffer, D., Bird, H., LaheY B., SchwabStone, M. (in press). Test-Retest reliability of the Diagnostic Interview Schedule for
Children (ver. 2.1): Parent, child and combined algorithms. Arch Gen Psychiatry.
17. Kendell, R.E. (1973). Psychiatric diagnoses: a study of how they are made. Br J Psyche, 122, 437-445.
18. Kendell, R. E. (1975). The role of diagnosis in psychiatry: Diagnosis as a practical decision making process, pp. 49-59. Blackwell: Oxford.
19. Kintz, B.L., Delprato, DJ., Mettee, D.R., Persons, C.E., Schappe, R.H. (1965). The experimenter effect. Psychological Bull, 63, 223-232.
20. Leaper, D. J., Horrocks, J. C., Staniland, J. R., de Dombal, F T (1972). Computer- assisted diagnosis of abdominal pain using "estimates" provided by clinicians. Br Med J, 1y 350-354.
21. Levine, S., Ancill, R. J., Roberts, A. P (1989). Assessment of suicide risk by computer delivered self-rating questionnaire: preliminary findings. Acta Psych Scand, 80, 216-220.
22. Lucas, R.W, Mullin, PJ., Luna, C.B.X., Mclnroy D. C. (1977). Psychiatrists and a computer as interrogators of patients with alcohol-related illnesses: a comparison. Br J Psych, 131, 160-167.
23. Sawyer, M. G, Sarris, A., Baghurst, P (1992). The effect of computer-assisted interviewing on the clinical assessment of children. Australian and New Zealand J Psychiatry, 26, 223-231.
24. Schwab-Stone, M., Shaffer, D., Dulcan, M., Jensen, P, Eisher, P, Bird, H., Goodman, S., Lahey, B., Lichtman, J., Canino, G., RubioStipec, M., Rae, D. (submitted for publication). Criterion validity of the NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC 2.3).
25. Setterberg, S., Ernst, M., Rao, U., Campbell, M., Carlson, G.A., Shaffer, D., Staghezza, B.M. (1991). Child psychiatrists' satisfaction and usage of DSM IIIR. J Am Acad Child Adolesc Psychiatry, 30, 652-658.
26. Shaffer, D., Fisher, P, Dulcan, M., Davies, M., Piacentini, J., Schwab-Stone, M, Lahey B., Bourdon, K., Jensen, P, Bird, H., Canino, G., Regier, D. (submitted for publication). The NIMH Diagnostic Interview Schedule for Children (DISC-2): Description, acceptability prevalence, and performance in the MECA study
27. Simon, RJ., Gurland, BJ. Fleiss, J.L., Sharpe, L. (1971). Impact of a patient history interview on psychiatric diagnosis. Arch Gen Psychiatry, 24, 437- 440.
28. Williams, T A., Johnson, J. Hand Bliss, E. L. (1975). A computer-assisted psychiatric assessment unit. Am J Psychiatry, 132, 10741076.
29. WHO (1993). International Classification of Diseases - Diagnostic Criteria for Research, 10th Edition, World Health Organization: Geneva.
30. Yokley J.M., Reuter, J. M. (1989). The computer assisted child diagnostic system: a research and development project. Computers in Human Behavior, 5, 277-295.