Section of Adolescent Psychiatry, University of Liverpool
Child and Adolescent Mental Health Service, Douglas, Isle of Man
Section of Adolescent Psychiatry, University of Liverpool, UK
Correspondence: Professor Simon Gowers, Mersey Regional Young People's Centre, Pine Lodge, 79 Liverpool Road, Chester CH2 1AW, UK
Declaration of interest The HoNOSCA base was supported by a grant from the NHS Information Authority.
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ABSTRACT |
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Aims To develop and test the properties of an adolescent, self-rated version of the scale (HoNOSCASR) against the established clinician-rated version.
Method A comparison was made of 6-weekly clinician-rated and self-rated assessments of adolescents attending two services, using HoNOSCA and other mental health measures.
Results Adolescents found HoNOSCASR acceptable and easy to rate. They rated fewer difficulties than the clinicians and these difficulties were felt to improve less during treatment, although this varied with diagnosis and length of treatment. Although HoNOSCASR showed satisfactory reliability and validity, agreement between clinicians and users in individual cases was poor.
Conclusions Routine outcome measurement can include adolescent self-rating with modest additional resources. The discrepancy between staff and adolescent views requires further evaluation.
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INTRODUCTION |
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METHOD |
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The reliability of HoNOSCASR was considered in two ways. Split-half reliability comprised a correlation between scores on odd and even numbered items for a series of 65 patients. Testretest reliability was rated for 24 in-patients tested on two occasions 1 week apart. Validity was tested by correlation with scores on self-reported and clinician-rated measures of psychopathology and general functioning, namely the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) and, for the eating disorder group, the MorganRussell schedule (Morgan & Hayward, 1988) and the Eating Disorders Inventory (EDI2; Garner, 1991).
Correlations between clinician- and user-rated versions enabled assessment of agreement between raters. The complete data were analysed using SPSS (SPSS, 1998).
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RESULTS |
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The self-rated version of HoNOSCA was completed by all adolescents at admission and discharge from the in-patient unit, although two failed to record mid-treatment review ratings. All out-patients completed self-ratings at each time point. There were therefore 359 self-ratings, representing a completion rate of 99.4%.
The completion of the self-rated version took 10-15 minutes for the first rating and about 5 minutes for subsequent ratings.
Reliability of HoNOSCASR
Split-half reliability showed a correlation between the odd- and
even-numbered scores of 0.73 based on a series of 65. Testretest
reliability of HoNOSCASR was explored in a subset of 24 patients to
whom the instrument was administered on two occasions, a week apart. As these
were in-patients with moderately severe disorder, it was assumed that there
was unlikely to have been much change in severity of difficulties between the
two rating points. The intraclass correlation coefficients varied from 0.32
for item 1 (antisocial and aggressive behaviour) to 0.88 for item 2 (attention
and concentration). The total score (Pearson's) correlation between time 1 and
time 2 was 0.806, P < 0.001
(Table 1).
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Validity of HoNOSCASR
The validity of HoNOSCASR was explored by correlating it with the
SDQ and (for the eating disorder series) the modified MorganRussell
severity schedule, which provides a global severity measure covering physical,
psychological and social adjustment
(Morgan & Hayward, 1988).
This measure has been widely used as a severity measure in anorexia nervosa
(Gowers et al, 2000).
The HoNOSCASR gave a correlation of 0.66 (P < 0.001) with
the adolescent-rated SDQ (n=39 cases); this compares with a
correlation of 0.397 between the clinician-rated version of HoNOSCA and the
SDQ (Yates et al,
1999). For the patients with eating disorders, HoNOSCASR
correlated moderately well with the total (self-report) EDI2 score
(r=0.629, n=53, P < 0.001), but only weakly (and
inversely, given the direction of scoring) with the clinician-rated
MorganRussell total score (r=-0.32, n=54,
P=0.018).
Patient view of clinical severity and outcome
At admission to the in-patient unit, or at presentation to the out-patient
service, the adolescent patients recorded comparable levels of difficulty to
the clinician ratings. For the in-patients (n=96) the mean total
admission score was 17.8, compared with the mean clinician rating of 19.6. For
the out-patients the mean scores were 14.9 and 18.8, respectively. There were,
however, notable differences between scale items
(Fig. 1), with clinicians
tending to give higher ratings to difficulties with peer relationships and
school attendance, while the young people themselves drew attention to
problems with attention and concentration (question 2) and scholastic and
language skills (question 5).
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During the course of treatment both the clinician-rated and self-rated versions of HoNOSCA demonstrated sensitivity to change. The in-patients reported a significant change over time, but slightly less than was reported by the staff (mean admission and discharge scores for 57 patients admitted for longer than 6 weeks were 18.44 and 12.82 self-rated, compared with clinician ratings of 18.35 and 9.75). The out-patients with eating disorders showed changes comparable with the clinician ratings. The changes in ratings over time for a consecutive smaller series from both services who were treated for a minimum of 4 months is shown in Table 2.
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Considering each scale item in turn, both raters reported improvement across the board, but young people were more positive about improvements in family relationships (item 12) and clinicians about behavioural items (items 1-3) (see Fig. 1).
Agreement between clinician and patient ratings
In individual cases agreement between clinician and patient ratings was
poor, with a correlation (Pearson's r) between HoNOSCA and
HoNOSCASR of 0.27 at presentation, rising to 0.58 at discharge. There
were notable differences by diagnosis, for the in-patients. Those with
psychoses tended to see themselves as having fewer problems than the
clinician's assessment, while those with emotional (chiefly affective)
disorders rated themselves as having more. A subgroup of patients with
incipient borderline personality disorder with poor peer relationships and
self-harm were the highest scorers on HoNOSCASR (mean admission score
24.6). The out-patient eating-disorder group showed much higher levels of
agreement, with a correlation of 0.58 at presentation and quite good agreement
(r=0.72) at discharge.
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DISCUSSION |
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A survey of 120 child and adolescent mental health services who had received training in the use of HoNOSCA suggested that half were using it 6 months later (further details available from the author upon request). Not all have been persuaded that the enthusiasm for HoNOSCA is fully justified, however (Jaffa, 2000), and other measures have since been developed. Alongside the PCS, the Strengths and Difficulties Questionnaire (Goodman, 1997) is a notable addition to the field. Incorporating both parent and child versions, the SDQ raises the question of who is the most relevant rater of a child's difficulties: clinician or child? One of the major reservations about HoNOSCA is that there is no patient perspective, and that clinicians might inevitably see progress when their interventions are being assessed.
Adolescent views of severity
Despite theoretical difficulties of insight and sometimes poor engagement
between adolescents and mental health services, this study shows that
adolescents are aware of their difficulties in a range of domains and will
freely admit to them. They often do not see difficulties in the same areas as
their treating clinicians, however. It is noteworthy that adolescents
themselves rate the subjective items (such as difficulty with concentration
and attention) as more problematic than staff do. This discrepancy highlights
the importance of therapeutic engagement in identifying difficulties and hence
common treatment aims.
Adolescent views on outcome
Despite the above reservations, in the two services studied adolescents
reported significant improvements with treatment, which spanned the duration
of intervention. This gave some support to the average length of treatment of
3-4 months. In the out-patient service, this view matched the progress seen by
staff.
Agreement between clinician and patient ratings
The correlation between HoNOSCA and HoNOSCASR is weak, particularly
for in-patients. These patients have been rated at the point of admission, and
their attitude to admission may be reflected in the scores. Approximately
one-third was suffering from an acute psychotic disorder, with predictable
levels of suspicion and lack of insight. The greater level of agreement
between clinicians and patients in the out-patient service requires
explanation. This could be related to the diagnostic homogeneity of the
out-patient group, but people with eating disorders are not noted for
acknowledging difficulties. A more likely explanation is that in an
out-patient service clinicians are more reliant on patient and informant
report in completing ratings, whereas in-patient staff can observe rather than
take the patient's word for performance in such areas as peer relationships.
It may therefore be that despite the lower levels of agreement, the clinician
ratings for the in-patients are more objective.
Therapeutic use of HoNOSCASR
The two services have used the clinician- and self-rated scores to monitor
progress through treatment with the patients themselves. In the out-patient
eating disorder service particularly, where patients are encouraged to change
behaviour, the scores provide regular feedback in addition to physical
measures and the scores on specific eating disorder self-report
questionnaires. Thus, patients with anorexia nervosa might be encouraged to
gain weight and judge for themselves whether this results in an improvement or
deterioration in general functioning by their own account. Progress in the
first 6 weeks can then be used to boost motivation for the next phase of
treatment. The possibilities for the therapeutic use of HoNOSCA to provide
feedback to patients look promising.
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Clinical Implications and Limitations |
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LIMITATIONS
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APPENDIX |
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In the last two weeks
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REFERENCES |
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Brann, P., Coleman, G. & Luk, E. (2001) Routine outcome measurement in a child and adolescent mental health service: an evaluation of HoNOSCA. Australian and New Zealand Journal of Psychiatry, 35, 370-376.[CrossRef][Medline]
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Shaffer, D., Gould, M. S., Brasic, J., et al (1983) A Children's Global Assessment Scale (CGAS). Archives of General Psychiatry, 40, 1228-1231.[Abstract]
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Yates, P., Garralda, M. E. & Higginson, I. (1999) Paddington Complexity Scale and Health of the Nation Outcome Scales for Children and Adolescents. British Journal of Psychiatry, 174, 417-423.[Abstract]
Received for publication May 17, 2001. Revision received October 18, 2001. Accepted for publication October 26, 2001.
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