JournalofPsychiatricResearch,42(8),694700doi:10.1016/j.jpsychires.2007.08.

002

Screeninginearlychildhoodforriskoflatermentalhealth
problems:Alongitudinalstudy
JakeM.Najmana,b, ,MichelleA.Herona,MohammadR.Hayatbakhsha,KaeleenDinglea,Konrad
Jamrozika,WilliamBorc,MichaelJ.OCallaghancandGailM.Williamsa
a
SchoolofPopulationHealth,UniversityofQueensland,HerstonRoad,HerstonQLD4006,Australia
b
SchoolofSocialScience,UniversityofQueensland,StLucia,QLD4072,Australia
c
MaterMisericordiaeChildrensHospital,SouthBrisbane,QLD4101,Australia

Correspondingauthor.Address:SchoolofPopulationHealth,UniversityofQueensland,Herston
Road,HerstonQLD4006,Australia.Tel.:+61733655180;fax:+61733655509.

Abstract

Depressioninchildhoodoradolescenceisassociatedwithincreasedratesofdepressionin
adulthood.Doesthisjustifyeffortstodetect(andtreat)thosewithsymptomsofdepressioninearly
childhoodoradolescence?Theaimofthisstudywastodeterminehowwellsymptomsof
anxiety/depression(AD)inearlychildhoodandadolescencepredictadultmentalhealth.Thestudy
sampleistakenfromapopulationbasedprospectivebirthcohortstudy.Ofthe8556mothers
initiallyapproachedtoparticipate8458agreed,ofwhom7223mothersgavebirthtoalivesingleton
baby.ChildrenwerescreenedusingmodifiedChildBehaviourChecklist(CBCL)scalesforinternalizing
andtotalproblems(TP)atage5andtheCBCLandYouthSelfReport(YSR)ADsubscaleandTP
scaleatage14.Atage21,asubsampleof2563youngadultsinthiscohortwereadministeredthe
CIDIAuto.Resultsindicatedthatscreeningatage5woulddetectfewlatercasesofsignificant
mentalillhealth.Usingacutpointof20%forinternalizingatchildage5yearstheCBCLhad
sensitivitiesofonly25%and18%formajordepressionandanxietydisordersat21years,
respectively.Atage14,theYSRgenerallyperformedalittlebetterthantheCBCLasascreening
instrument,butneitherperformedatasatisfactorylevel.Ofthechildrenwhowerecategorisedas
havingYSRADat14years30%and37%metDSMIVcriteriaformajordepressionandanxiety
disorders,respectively,atage21.Ourfindingschallengeanexistingmovementencouragingthe
detectionandtreatmentofthosewithsymptomsofmentalillnessinearlychildhood.

Keywords:Childhood;Adolescence;Adult;Psychopathology;Screening

1.Introduction

Thereisnowsubstantialevidencethatsomementalhealthproblemsmayhaveanearlyageofonset
([Costelloetal.,2006]and[Dierkeretal.,2001])andhighlevelsofrecurrenceoverthelifecourse
([Birmaheretal.,1996]and[Rutteretal.,2006]).Crosssectionalstudiesinvolvingrespondentrecall
aresupportedbylongitudinalstudiesconfirmingtheassociationbetweenearlyageofonsetand
recurrenceofmentalhealthproblemsovertheadultlifecourse.Usingmaternalreportsof
psychopathologyatage13andaninterviewerratedchecklistat24yearsofage,Lynametal.(2007)
foundacorrelationofr=0.31betweenadolescentandyoungadultmentalhealthscores.Repeated
assessmentsofanxietyanddepressionfromchildhood(age11years)toage32yearsusingdata
fromtheDunedinbirthcohortalsosuggestthatbothanxietyanddepressionarefrequently
characterisedbyadolescentonsetandrecurrenceoverthelifecourse(Moffittetal.,2007).
Furthermore,thereissomeevidenceindicatingthatearlyageofonsetmaypredictamorechronic
coursefordepression([Kessleretal.,2001]and[Kovacs,1997]).Thesefindingsraisethepossibility

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JournalofPsychiatricResearch,42(8),694700doi:10.1016/j.jpsychires.2007.08.002

thatyoungchildrenandadolescentsmightbescreenedforsymptomsofmentalillnesswiththeaim
ofrecruitingthosechildrenwithhighscoresintotreatmentand/orpreventionprograms.

Thecaseforearlyinterventionfundamentallydependsontheextenttowhichlowageofonset
predictssignificantillhealthinadulthood.Manyearlyinterventionandtreatmentprogramsrequire
thescreeningofchildrentoidentifythoseatparticularrisk.Suchapproacheshaveintuitiveappeal
but,asWilsonandJungner(1968)notedalmost40yearsago,thereisalonganddemandinglistof
criteriathatshouldbemetbeforescreeningprogramsareestablished.Threeparticularissues
confrontanyadvocatesofscreeningchildrentoidentifyandintervenewiththoseathighriskoflater
problemswithmentalhealth.First,thereistheneedforascreeningprocessorinstrumentthathas
acceptablevalidity,thatis,bothhighsensitivity(thecapacitytoidentifyindividualswho
subsequentlyexperienceamentalillness)andhighspecificity(thecapacitytoexcludecorrectly
thoseindividualswhosubsequentlydonotexperienceamentalillness).Specificitymaybe
particularlyimportantinsuchastigmatizedareaasmentalhealth,asmislabellingahealthychildas
beingathighriskcoulditselfcarryadverseconsequences,evenifanysubsequentpreemptive
interventionwasentirelyharmless.

Thesecondissueconcernsthetimingofthescreeningassessmentorassessments,givenevidence
thattherearesensitiveperiodsinachildsdevelopmentwhenexposuretoadverseenvironments
caninitiatechangesthathavelongtermconsequencesformentalhealth.Logically,screeningwould
followratherthanprecedesuchperiods.Third,havingassessedchildrenwithanappropriate
instrumentatappropriatetime(s),onemusthaveavailableandbeabletodeliveranintervention
thatreduceslatermentalhealthproblemsamongthosedeemedtobeathighriskofsuchproblems.

Thepresentpaperdealsespeciallywiththefirsttwooftheseissues,thevalidityofapotential
screeninginstrumentandthetimingofpossibleassessments.Inaddition,thisstudyexploresthe
positivepredictivevalue(PPV);thatistheproportionoftheindividualswithapositivescreeningtest
wholaterdevelopasignificantproblemwiththeirmentalhealth.Finally,thisstudyexaminesthe
proportionofindividualswhoarelabelledasbeingathighriskbutwhodonotmeetthecriteriafor
mentalhealthdisordersby21yearsofage(falsepositives).

2.Materialsandmethods

2.1.Participants

WeuseddatafromtheMaterUniversityStudyofPregnancy(MUSP),aprospectivelongitudinal
studyofaconsecutivecohortofindividualsborninBrisbane,Australiabetween1981and1983ata
majorpublichospital(MaterMisericordiaeHospital).Recruitmentproceduresforthelargerstudy
havebeendescribedelsewhere([Hayatbakhshetal.,2007]and[Najmanetal.,2005]).Ofthe8556
mothersinitiallyapproachedtoparticipateinthestudy8458(98.9%)agreed.Thecohortconsistsof
7223womenwhodeliveredalivesingletonbabywhowasnotadoptedout.Thisrepresents87%of
allwomenwhoattendedtheantenatalclinicduringthestudyperiod.Motherscompleted
questionnairesattheirfirstantenatalclinicvisit,35daysafterthebirth,6monthsafterthebirth,5
years,14yearsand21yearsafterthebirth.Childrencompletedtheirownquestionnairesat14and
21years.Duetoashortageoffunding,onlyasubsetofyoungadults(n=2563)wereadministered
theCompositeInternationalDiagnosticInterview,computerizedversion2.1(CIDIAuto)at21years
(WorldHealthOrganization,1997).Theaverageageofoffspringparticipantswas20.4years
(SD=0.8),51.0%werefemale,24.6%hadtertiaryeducation,54.6%hadcompletedhighschooland
20.8%hadsomeprimaryorsecondaryschooleducation.

Finalpublishedversionavailableathttp://www.sciencedirect.com/science/journal/00223956
JournalofPsychiatricResearch,42(8),694700doi:10.1016/j.jpsychires.2007.08.002

2.2.Measures

MotherscompletedamodifiedversionoftheChildBehaviourChecklist(CBCL)atthe5and14year
followups,andchildrencompletedtheYouthSelfReport(YSR)at14years([Achenbach,1991a]and
[Achenbach,1991b]).Thesewidelyusedandvalidatedinstrumentsservedasscreeningtestsfor
latermentalhealthproblems.Theyprovidestandardizedchecklistsofchildandadolescent
behaviourproblemsandcompetencies.TheCBCLisdesignedforcompletionbyparentsofchildren
aged418,andgeneratesscoresforeightsyndromes:withdrawal,somaticcomplaints,
anxiety/depression(togetherconstitutingtheInternalizingScale),delinquentbehaviour,aggressive
behaviour(togetherconstitutingtheExternalizingScale),socialproblems,thoughtproblemsand
attentionproblems.Atotalproblemscoreisderivedbysummingtheindividualitemscores.Inthis
studytheInternalizing(Cronbachs=0.76)andtotalproblems(TP)(Cronbachs=0.90)scales
wereusedat5years,andtheanxiety/depression(AD)(Cronbachs=0.85)andTP(Cronbachs
=0.95)scaleswereusedat14years.Theitemscompletedatthe5yearfollowup,whileusedto
measureinternalizingsymptoms,largelycomprisedsymptomsofAD.

Themodified(shortform)oftheCBCLcompletedbymothersat5yearsincluded33ofthe113items
fromtheoriginalscale.Itemsselectedassessedthemostcommonlyoccurringbehavioursin5year
old.Furthermore,respondentsinourstudyrateditemsasoccurringoften,sometimesornever
ratherthanonathreepointscalerangingfrom0nottrueto2verytrueoroftentrue,as
describedintheoriginalscale.Factoranalysesandreliabilityestimatesofsubscalesproduced
resultsconsistentwithAchenbachsdata([Achenbach,1991a]and[Najmanetal.,2001]).In
addition,asampleof76parentswhose6yearoldchildrenwereatschoolalsocompletedthelong
formoftheCBCL.Therewereverystrongcorrelations(externalizingr=0.94,internalizingr=0.89)
betweentheshortandfullformsoftheCBCL(Najmanetal.,1997).

TheYSRisbasedontheCBCLandobtainsselfreportsfrom11to18yearold.Thesechecklistshave
beenshowntobereliableandarguablyvalidindicatorsofproblembehaviour([Achenbach,1991a]
and[Achenbach,1991b]).ThecompleteADscale(Cronbachs=0.84)andTPscale(Cronbachs
=0.94)wereusedandrespondentsweregiventhemodifiedoptionsofoften,sometimes,and
rarely/never.

TheCIDIAutoisastructuredinterviewthatassessesmentaldisorders,bothlifetimeandcurrent,
accordingtothecriteriaoftheICD10(WorldHealthOrganization,1993)andDSMIV(American
PsychiatricAssociation,1994).Theinstrumentcontains276questionsaboutpotentialsymptoms
andassessessymptomseverity,helpseekingbehaviour,psychosocialimpairmentsandother
episoderelatedinformation.TheCIDIAutoisafullycomputerizedversionofthestandardCIDI,
whichcanbeadministeredeitherbyaninterviewerorcompletedbytherespondent.Thedatafrom
theCIDIareenteredintoascoringprogramwhichgivesoutputaccordingtothediagnosticcriteria
satisfied.TheCIDIAutohasgoodinterraterandtestretestreliability(Petersetal.,1998)andhas
acceptablevalidity(PetersandAndrews,1995).WeusedtheCIDIAutotoassesslifetimediagnoses
ofDSMIVMajorDepressiveDisorder,anyDSMIVAnxietyDisorderandanyDSMIVMentalHealth
Disorder.

2.3.Statisticalanalysis

Weusedlogisticregressiontoestimatetherisk(oddsratio(OR)and95%confidenceintervals(95%
CI))ofhavingaDSMIVmentalhealthproblembyage21foreachAchenbachmeasureofADandT
Passessedatchildage5and14years.WethenexaminedthesensitivityandspecificityoftheCBCL
(aged5and14years)andtheYSR(aged14years)aspredictorsofCIDIAutooutcomesat21yearsof
age.Asboththesensitivityandspecificityofatestareinfluencedbythecutoffpointabovewhich

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JournalofPsychiatricResearch,42(8),694700doi:10.1016/j.jpsychires.2007.08.002

individualsareconsideredtohaveproblems,weusedthreedifferentcutoffsthemostextreme
5%,10%and20%ofscores,todetermineifselectingaparticularproportionofthesampleforearly
occurringpsychopathologymayimprovepredictionordetectionofcasesat21years.Ateachcut
off,wealsocalculatedthePPV,theproportion(%)ofscreenpositiveindividualswhoactuallydid
reportamentalhealthproblematage21,andalsotheproportionofthepopulationthatwas
identifiedaspositivebyascreeningtoolbutwasnotdiagnosedashavingmentalhealthproblemby
DSMIV(falsepositives).

Becauseofresourceconstraints,only2563participantswereadministeredtheCIDIAutoat21years
(35.5%ofthe7223childrenoriginallyenrolledinMUSP).Ouranalysesincludeonlythose
participantsinMUSPforwhomwehaddataat5yearsor14years,orboth,aswellasat21years.
Thus,samplesizevariesslightlyaccordingtowhichassessmentorscreeningtestisbeingconsidered.

Todeterminewhetherlosstofollowupat21yearsaffectedthevalidityofourfindings,we
undertookasensitivityanalysisusinginverseprobabilityweightsreflectingthechancesofhaving
missingoutcomedata(Hoganetal.,2004).Webeganbyconstructingalogisticregressionmodel
examiningtheassociationofallindependentvariablesusedinourprimaryanalyseswithhaving
completedataornot.Theregressioncoefficientsfromthismodelwerethenusedtodetermine
probabilityweightsforthecovariatesinthemainanalyses.Inthecurrentstudy,losstofollowup
waspredictedbyTPatchildage5yearsandADatchildage14years.ChildrenwithTPat5years
orADat14years(YSR)weremorelikelytodropoutthestudyby21years(pvalue<0.05).The
resultsfromanalysesincludinginverseprobabilityweightingbasedonthesefactorsdidnotdiffer
fromtheunweightedanalysespresentedhere,suggestingthatourresultswerenotsubstantially
affectedbyselectionbias.

3.Results

Of2563participantswhowereadministeredtheCIDIAutoatthe21yearfollowup,508(19.8%)
mettheDSMIVcriteriaforhavingeverhaddepression.ThecorrespondingfiguresfortheDSMIV
criteriaforalifetimediagnosisofanxietywere638and24.9%,whileforanylifetimeDSMIVmental
illnessdiagnosis,theywere896and35.0%.

Table1showsthatinternalizingandTPat5yearsweremodestlyassociatedwithanxietydisorder
andanymentalhealthdisorderat21years,respectively.Childrenwhoscreenedpositiveat5years
were,atmost,60%morelikelytohavehadanymentalhealthdisorderbyearlyadulthood.The
associationsforboththeCBCLandYSRat14yearswithDSMIVdiagnoseswerestrongerthanfor
theCBCLat5years,withYSRscoresprovidingthestrongestpredictorsofDSMIVmentalhealth
problemsat21years.However,importantlytherewerenosignificantdifferencesinthestrengthof
predictionforthevariouscutoffsexaminedinthestudy.

Table1:PredictionofDSMIVmentalhealthdisordersat21yearsby5and14yearCBCLandYSR

Table2presentstherelationshipbetweenCBCLscoresatthe5yearfollowupandCIDIAuto
diagnosesat21years.Thesensitivityofthescreeningassessmentvariedfrom5.2%fortheTPscore
oftheCBCLasapredictorofanylifetimementalhealthdisorder,usingacutoffforcasenessat
screeningof5%,to28.3%fortheinternalizingscoreoftheCBCLasapredictorofanyDSMIV
diagnosisofanxietydisorder,applyingacutoffof20%atscreening.Asexpected,specificityfellas

Finalpublishedversionavailableathttp://www.sciencedirect.com/science/journal/00223956
JournalofPsychiatricResearch,42(8),694700doi:10.1016/j.jpsychires.2007.08.002

moreliberalcutoffswereadoptedinpursuitofgreatersensitivity.Theeffectofchangesincutoffs
onthePPV,whichdependsonacombinationofspecificityandprevalence,wasrelativelyminor.
However,thePPVsforallDSMIVdiagnosesweregreaterthanforaDSMIVdiagnosisofdepression
oranxiety.Theproportionofthescreenedpopulationincorrectlyclassifiedasbeingathighrisk
(falsepositives)variedfrom55.2%upto80.8%whendifferentcutoffswereappliedtosubscalesof
theCBCLatchildage5years.Takingthestrongestpredictionwehaveasanillustration,therewere
566casesofDSMIVanxietyat21years,ofwhom160(sensitivityof28.3%)werepredicted,leaving
406cases(71.7%ofallcases)at21yearsundetected.Ofthe530personsidentifiedatthe5year
followupasbeingatelevatedrisk,370didnotreachthecriteriaforacaseofanxietyatthe21year
followup(69.8%falsepositives).

Table2:PredictingCIDIAutolifetimediagnosisofDSMIVdepression,DSMIVanxietyandall
DSMIVcategoriesat21yearsusing5yearCBCLscreeningtestscoresoninternalizingandtotal
problemcores
Cut Cases
Cases False
offfor at5 Sensitivity Specificity PPV
Endpoint Subscale at5 positives
cases and21 (%)a (%)b (%)c
years (%)d
(%) years
Depression(DSMIV): Internalizing 5 156 30 6.7 93.2 19.2 80.8
TotalN=2311 10 252 50 11.1 89.1 19.8 80.2
DSMIVcases=450 20 529 113 25.1 77.6 21.4 78.6

Anxiety(DSMIV): Internalizing 5 157 50 8.8 93.9 31.8 68.2

TotalN=2313 10 253 82 14.5 90.2 32.4 67.6
DSMIVcases=566 20 530 160 28.3 78.8 30.2 69.8

AllDSMIV Total
5 98 41 5.2 96.2 41.8 58.2
categories: problem
TotalN=2315 10 201 90 11.3 92.7 44.8 55.2
DSMIVcases=796 20 461 182 22.9 81.6 39.5 60.5
a
TheproportionofpeoplewithDSMIVdiagnosiswhohadapositivescreeningtest.
b
TheproportionofpeoplewithanegativeDSMIVdiagnosiswhohadanegativescreeningtest.
c
Positivepredictivevalue:ofthosewhowerescoredpositiveonthescreeningtest,theproportionwhoalso
subsequentlymettheDSMIVcriteriaforcaseness.
d
TheproportionofpeoplescreeningpositivewhodidnotmeetDSMIVcriterialater.

Table3usestheYSRandCBCLdatacollectedatthe14yearfollowuptopredictoutcomesassessed
usingtheCIDIAutoat21years.Therearethreepatternsintheseresultsthatwarrantattention.
Again,relaxingthecriterionforcasenessatscreeningsystematicallyincreasessensitivitybutreduces
specificity.Evenwith20%cutoffsatage14,onlyminoritiesofthelifetimecasesreportedatage21
aredetected.Ofthe482casesofCIDIAutodepressionatthe21yearfollowup,196(40.7%)are
detectedusingthe20%cutofffortheYSR.Usingthesametestandcutoff,thereare636screen
positiveindividualsatage14years,ofwhom440(69.2%)arefalsepositives.

Finalpublishedversionavailableathttp://www.sciencedirect.com/science/journal/00223956
JournalofPsychiatricResearch,42(8),694700doi:10.1016/j.jpsychires.2007.08.002

Table3:PredictingCIDIAutolifetimediagnosisofDSMIVdepression,DSMIVanxietyandall
DSMIVcategoriesat21yearsusing14yearYSRandCBCLscreeningtestscoreson
anxiety/depression(AD)andtotalproblem(TP)scores

Cases
Cases False
Cutofffor at14 Sensitivity Specificity PPV
Endpoint Subscale at14 positives
cases(%) and21 (%)a (%)b (%)c
years (%)d
years
YSR(AD) 5 176 67 13.9 94.4 38.1 61.9
Depression CBCL(AD) 173 52 10.8 93.8 30.1 69.9
(DSMIV):Total YSR(AD) 10 236 84 17.4 92.2 35.6 64.4
N=2435,DSM CBCL(AD) 217 65 13.5 92.2 30.0 70.0
IVcases=482 YSR(AD) 20 636 196 40.7 77.5 30.8 69.2
CBCL(AD) 595 161 33.4 77.8 27.1 72.9

YSR(AD) 5 177 81 13.5 94.8 45.8 54.2

Anxiety(DSM CBCL(AD) 173 64 10.7 94.1 37.0 63.0
IV):Total YSR(AD) 10 237 99 16.6 92.5 41.8 58.2
N=2438,DSM CBCL(AD) 218 81 13.5 92.6 37.2 62.8
IVcases=598 YSR(AD) 20 636 239 40.0 78.4 37.6 62.4
CBCL(AD) 596 204 34.1 78.6 34.2 65.8

YSR(TP) 5 124 66 7.8 96.4 53.2 46.8

AllDSMIV CBCL(TP) 119 53 6.3 95.9 44.5 55.5
categories:Total YSR(TP) 10 240 132 15.6 93.2 55.0 45.0
N=2441,DSM CBCL(TP) 227 110 13.0 92.7 48.5 51.5
IVcases=845 YSR(TP) 20 513 270 32.0 84.8 52.6 47.4
CBCL(TP) 523 231 27.3 81.7 44.2 55.8
a
TheproportionofpeoplewithDSMIVdiagnosiswhohadapositivescreeningtest.
b
TheproportionofpeoplewithanegativeDSMIVdiagnosiswhohadanegativescreeningtest.
c
Positivepredictivevalue:ofthosewhowerepositiveonthescreeningtest,theproportionwhoalso
subsequentlymettheDSMIVcriteriaforcaseness.
d
TheproportionofpeoplescreeningpositivewhodidnotmeetDSMIVcriterialater.

Second,althoughthedifferencesincapacityoftheYSRandCBCLtopredictoutcomesaremodest,
theyconsistentlyfavourtheYSR,whichhasslightlybettersensitivityandalmostidenticalspecificity
whencomparedwiththeCBCL.Nevertheless,theoverallpatternsuggeststhatscoresspecificallyon
theADsubscaleoftheYSR/CBCLatage14provideonlyalimitedpredictionofthatindividuals
responsestotheCIDIAutoat21yearsofage.Finally,inthefaceofonlymoderatesensitivityand
PPVsandimperfectspecificity,weagainseesizeableproportionsofchildrenclassifiedatage14as
caseswhodonotgoontoreportDSMIVdiagnosesatage21.

4.Discussion

Wehaveusedthedatafromalargeprospectivecohorttoexaminetheviabilityofscreeningchildren
andadolescentstodetectpsychopathologyoccurringbyearlyadulthood.Childrenatages5and14
yearswereassessedusingtheCBCL(5and14years)andtheYSR(14years)atstagesintheirlife
coursewhicharearguablysensitiveperiodsandwhichhavebeenassociatedwiththeonsetof
psychopathology.Wehaveusedthreedifferentcriteria(cutoffs)forcasenessatscreeningatages5
and14yearstopredictCIDIAutodepression,anxietyandallDSMIVdiagnosesat21yearsofage.
Thefindingsareconsistentinanumberofways.WhilethesensitivityoftheCBCLscreeningatage5

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improveswiththeincreaseintheproportionofindividualsacceptedascases,evenwitha20%
cutoff,onlyabout20%ofcasesoccurringbyyoungadulthoodaredetected.Thedisadvantageof
relaxingthethresholdforcasenessinchildhoodisthatthevastmajorityofthoseselectedaslikely
tomanifestpathologysubsequentlydonotmeettheDSMIVcriteriaforcasenessat21years.

Theresultsaresomewhatmorepromisingwhenadolescentsarescreenedat14yearsofage.
Sensitivityimproveswithscreeninginadolescencewhilespecificityremainsover80%.Sensitivityis
somewhatbetterfortheYSRcomparedwiththeCBCL(selfreportsappeartoprovidebetter
predictionsthanmaternalreports)andthehighestcutoffsclearlyleadtobetterpredictionof
psychopathologyat21yearsofage,albeitatthecostofmorefalsepositives.However,even
employingacutoffontheYSRof20%,only32.0%ofindividualswithanyDSMIVdiagnosisby21
yearsaredetectedbythescreeningassessment.Whileourdatasuggestthatcasedetectionator
aroundpubertyispreferabletoscreeninginearlychildhood,theimpactontheincidenceof
subsequentmentalillhealthwouldstillbeverylimitedevenifaperfectlyefficaciousintervention
weredeliveredtoallscreenpositiveindividuals.

4.1.Clinicalimplications

Thefindingsfromthislargescale,populationbasedprospectivelongitudinalstudyraisesome
importantquestionsaboutthevalueofearlychildhoodscreeningformentalillness.Theychallenge
thecaseforscreeningchildrenfordepressioninearlychildhood.Ourfindingsfavourscreeningfor
psychopathologyinadolescenceratherthanearlychildhood,usingchildselfreportsratherthan
maternalreports,andusingmoreratherthanlessliberalcriteriaforcasedetection.Themain
disadvantagesofearlydetectionofpsychopathologyarethatthevastmajorityofpersonsidentified
atscreeningdonotgoontobecomecasesat21yearsofage,andthemajorityofcasesat21years
ofagewillremainundetectedviascreening.Substantialnumbersofindividualsnotactuallyatriskof
youngadultonsetofpsychopathologywouldbeincorrectlylabelledandoffered,orsubjectedto,
treatmentsthatarenotindicatedforthem.

OurfindingsarestrongestwhenthescreeningtestisusedtopredictanyDSMIVdiagnosesatthe
21yearfollowup.Thissuggeststhatthescreeningtestsweusedarenonspecificindetecting
subsequentcasesofimpairedmentalhealth,andconfirmsconcernsthattheclinicaldistinction
betweenanxietyanddepressionisnotsupportedbypopulationdata(Moffittetal.,2007).
Judgmentsaboutwhethertoscreenforearlyevidenceofmentalhealthproblemsmustdepend
uponthecost,effectivenessandpossibleharmsassociatedwithanyproposedintervention.Tobe
useful,anyinterventionbasedonourscreeningtestswouldneedtobeavailabletoalargeminority
ofthepopulation,ofrelativelylowcost/intensity,somewhateffectiveandwithfewnegative
consequencesforthosewhoarethesubjectedtoit.Ourfindingschallengeanexistingmovement
encouragingthedetectionandtreatmentofthosewithsymptomsofmentalillnessinearly
childhood.Wehavebeenunabletolocateasinglepaperusingaprospectivedesignwhichdisagrees
withourdata.

4.2.Limitations

Thereareanumberoflimitationswhichmustbeconsideredwhenassessingtheabovefindings.
First,wehaveusedashortformoftheCBCL(internalizing)subscaleat5yearsofage.Whilethis
subscalehasahighcorrelationwiththefullinternalizingsubscale,itmayneverthelessbeless
discriminatingthanthefullsubscaleinidentifyingsubsequentcaseness.Elsewherewehave
demonstratedstrongcorrelationsbetweentheshortandlongformsoftheCBCL(Najmanetal.,
1997).

Finalpublishedversionavailableathttp://www.sciencedirect.com/science/journal/00223956
JournalofPsychiatricResearch,42(8),694700doi:10.1016/j.jpsychires.2007.08.002

Second,itcouldbesuggestedthatthefullCBCLshouldbeusedat5yearsofage,ratherthanthe
internalizingsubscale.Theinternalizingsubscalecorrelatedhighlywiththefullscaleitis,afterall,a
significantcomponentofthefullCBCLscale.Wehaveconcentratedontheinternalizingsubscale
becausewewishedtoassessitspredictivecapacityforADoutcomesat21years,thesebeing
amongstthecommonestmentalhealthproblems.Moregenerally,somemayarguethatwehave
usedthewronginstrumentsforscreeningentirely,despitetheirstrongrecordsintheassessmentof
behaviourinchildhoodandadolescence,orthatage21istoosoontoexpecttoseeoutcomes.While
otherscreeningtestareavailable(e.g.theStrengthsandDifficultiesQuestionnaireSDQ),
comparisonsofthesetestsagainsteachotherandexternalvalidationssuggestthattheyarestrongly
correlatedandthattheyproducecomparableresults([GoodmanandScott,1999]and[Jensenetal.,
1996]).Wedoagreethatlongerfollowupofourcohortisdesirable.

Athirdlimitationrelatestowhatisknownaboutthenaturalhistoryofmentalillness.As
impairmentsinmentalhealthmayfluctuateovertime,manyparticipantsinthisstudymayhavehad
mentalhealthproblemsearlyintheirlifecoursethatwerenotevidentatthetimeofscreening.If
thatweretrue,itwouldargueforscreeningonmultipleoccasions,orforinclusionofquestions
aboutpreviousmentalhealthproblemsinscreeningprotocols.

Fourth,only2563youngadultswereadministeredtheCIDIAuto.Whilecostconsiderationswere
theprimaryreasonforthereducednumbers,thereisapossibilitythatthesampleselectedmaynot
bemorebroadlyrepresentativeofthepopulation.Wehavefoundthatthoselosttofollowupare
disproportionatelyfromlowersocioeconomicbackgrounds,andcomefromfamilieswithamore
frequenthistoryofmentalhealthproblems.However,extensivestatisticalanalysessuggestthat
thoselosttofollowupornotincludedinaspectsoffollowupdonotadverselyaffecttheinternal
validityofthefindingsfromMUSPandmaywellnotunderminetheirexternalvalidityeither
(Najmanetal.,2005).AsdescribedinSection2,wehaveusedinverseprobabilityweightingand
foundthatselectiveattritionisunlikelytohavehadanymaterialimpactonourresults.

5.Conclusions

Wehaveconfirmedthatwhilechildoradolescentmentalhealthimpairmentpredictsmentalhealth
problemsinearlyadulthood,theassociationisnotsufficientlystrongtorecommendscreeningand
earlyinterventioneitherinearlychildhoodorevenpossiblyinadolescence.Totheextentthatthere
isacaseforscreening,wefoundthatscreeningshouldbedelayeduntiladolescentperiod,itshould
involvelargercutoffsthangenerallyusedtoselectcasenessinthechildhoodoradolescentperiod,
andanyensuinginterventionwouldneedtosatisfyanumberofdemandingcriteria.

TheuseofscreeninginstrumentsearlyinthelifecoursetopredictDSMIVdiagnosticoutcomesin
adulthoodinvolvestwosomewhatdifferentsourcesoferror.Thefirstistheuseofascreening
instrumentwhichdoesnotdirectlymapontodiagnosticcriteria.Whileonewouldexpecta
screeninginstrumenttobeassociatedwithadiagnosticoutcome,theassociationmaybeofonly
moderatemagnitude.Second,thefluctuatingnatureofanxietyanddepressionoverthelifecourse
maymeanthatsomecasesaremissed.Irrespectiveofthestudylimitationsandsomepossible
ambiguityininterpretingthedata,thefindingsareconsistentinsuggestingthatscreeningchildren
oradolescentsforearlyevidenceofimpairedmentalhealthmaynotleadtoimprovedmentalhealth
inapopulation.

Finalpublishedversionavailableathttp://www.sciencedirect.com/science/journal/00223956
JournalofPsychiatricResearch,42(8),694700doi:10.1016/j.jpsychires.2007.08.002

Conflictofintereststatement

Noauthorshaveanyactualofpotentialconflictofinterestincludingfinancial,personalorother
relationshipswithotherpeopleororganizationswhichcouldinappropriatelyinfluence,orbe
perceivedtoinfluence,ourwork.

Contributors

J.M.Najmandevelopedthestudyaimsanddesign.ThemainanalyseswereundertakenbyJ.M.
NajmanandM.A.Heron.M.A.Heronalsodraftedtheliteraturereview.M.R.HayatbakhshandK.
Dinglecontributedtothedataanalysesandtheinterpretationoffindings.J.M.NajmanandM.A.
Heronwrotethefirstdraftofthemanuscript.J.M.Najman,M.OCallaghan,W.BorandG.M.
WilliamsareresponsiblefortheconceptualdevelopmentandcontinuedmanagementoftheMater
UniversityStudyofPregnancyanditsoutcomesandtakeresponsibilityfortheintegrityandaccuracy
ofthedataanalysis.J.M.NajmanandK.Jamrozikediteddraftsofthepaperandcontributedtothe
discussionandconclusion.Allauthorscontributedtoandhaveapprovedthefinalversionofthe
paper.

Roleoffundingsource

FundingforthisstudywasprovidedbyNHMRCGrant210298.TheNHMRChadnofurtherrolein
studydesign;inthecollection,analysisandinterpretationofdata;inthewritingofthereport;andin
thedecisiontosubmitthepaperforpublication.

Acknowledgments

TheauthorsthanktheMUSPparticipants,theMUSPResearchanddatacollectionteams,especially
RosemaryAird,andMUSPDataManagerGregShuttlewoodfortheirsupport.Thecorestudywas
fundedbytheNationalHealthandMedicalResearchCouncil(NHMRC)ofAustralia,buttheviewsin
thispaperarethoseoftheauthorsanddonotnecessarilyreflecttheviewsofanyfundingbody.

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