Comparing mental health semi-structured diagnostic interviews and symptom checklists to predict poor life outcomes: an 8-year cohort study from childhood to young adulthood in Brazil

Abstract

Background: Semi-structured diagnostic interviews and symptom checklists present similar internal reliability. We aim to investigate whether they differ in predicting poor life outcomes in the transition from childhood to young adulthood.

Methods: For this longitudinal study, we used data from the Brazilian High Risk Cohort Study for Childhood Mental Health Conditions. Eligible participants were aged 6-14 years on the day of study enrolment (January to February, 2010) and were enrolled in public schools by a biological parent in Porto Alegre and São Paulo, Brazil. 2511 young people and their caregivers were assessed at baseline in 2010-11, and 1917 were assessed 8 years later (2018-19; 76·3% retention). Clinical thresholds were derived using semi-structured parent-report interview based on the Diagnostic and Statistical Manual of Mental Disorders, according to the Developmental and Well-being Assessment (DAWBA), and clinical scores as defined by the Child Behavior Checklist (CBCL; T-score ≥70 considered positive caseness). At 8 years, participants were assessed for a composite life-threatening outcome (a composite of death, suicide attempts, severe self-harm, psychiatric inpatient admission, or emergency department visits) and a composite poor life chances outcome (a composite of any criminal conviction, substance misuse, or school dropout). We evaluated the accuracy of DAWBA and CBCL to predict these outcomes. Logistic regression models were adjusted for age, sex, race or ethnicity, study site, and socioeconomic class.

Findings: DAWBA and CBCL had similar sensitivity, specificity, predictive values, and test accuracy for both composite outcomes and their components. Any mental health problem, as classified by DAWBA and CBCL, was independently associated with the composite life-threatening outcome (DAWBA adjusted odds ratio 1·62, 95% CI 1·20-2·18; CBCL 1·66, 1·19-2·30), but only CBCL independently predicted poor life chances (1·56, 1·19-2·04). Participants classified by both approaches did not have higher odds of the life-threatening outcome when compared with participants classified by DAWBA or CBCL alone, nor for the poor life chances outcome when compared with those classified by CBCL alone.

Interpretation: Classifying children and adolescents based on a semi-structured diagnostic interview was not statistically different to symptom checklist in terms of test accuracy and predictive validity for relevant life outcomes. Classification based on symptom checklist might be a valid alternative to costly and time-consuming methods to identify young people at risk for poor life outcomes.

Funding: Conselho Nacional de Desenvolvimento Científico e Tecnológico; Fundação de Amparo à Pesquisa do Estado de São Paulo; and Medical Research Council, European Research Council.

Translation: For the Portuguese translation of the abstract see Supplementary Materials section.

Figure 1

Associations of any mental health diagnosis, as assessed by DAWBA and CBCL, with composite life-threatening and poor life chances outcomes The analysis was performed in separated regression models (A); using both classification approaches in the same regression models (B); and by comparing not being classified by either approach, by DAWBA only, or by CBCL only, with being classified by both DAWBA and CBCL (C). All regression models were adjusted for covariates (age, sex, ethnicity, socioeconomic class, and study site) and weighted for attrition. CBCL=Child Behavior Checklist. DAWBA=Developmental and Well-being Assessment. OR=odds ratio.

Figure 2

Absolute explained variance (A) and explained variance relative to regression models using covariates only (B) The x-axis shows explained variance in A and the proportion of added explained variance in B, calculated by dividing models with classification approaches as predictors by the explained variance of regression models including covariates only. Regression models used the composite life-threatening or poor life chances outcomes as dependent variables. The independent variables were the basic model (age, sex, ethnicity, study site, and socioeconomic group), DAWBA, CBCL (as separated models), DAWBA and CBCL in the multiple regression model, and a nominal classification variable containing participants classified by both DAWBA and CBCL (comparator group), DAWBA only, CBCL only, or neither. All regression models were adjusted for covariates (age, sex, ethnicity, study site, and socioeconomic group) and weighted for attrition. CBCL=Child Behavior Checklist. DAWBA=Developmental and Well-being Assessment.