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The Child and Adolescent Psychiatric Assessment (CAPA)
ADRIAN ANGOLD, M.R.C.PSYCH.,AND E. JANE COSTELLO, PH.D.
ABSTRACT
Objective: To describe the Child and Adolescent Psychiatric Assessment (CAPA). The base interview covers the age range
from 9 to 17 years. Method: The interview glossary that provides detailed operational definitions of symptoms and severity
ratings is described, and psychometric data and further developments of the interview are presented. Results: Across 5,962
parent-child interviews, the core sections of the CAPA (psychiatric symptoms, functional impairment, demographics, family
structure and functioning) took on average 59 minutes for children and 66 minutes for parents. Test-retest reliability for diagnoses ranged from K = 0.55 for conduct disorder (CD) to K = 1 .O for substance abuse/dependence. Validity as judged by 10
different criteria was good. Developments of the CAPA include a shorter “gateway” version using core symptoms as screen
items, a Spanish version, and versions for twin studies, use with young adults (YAPA), and preschool-age children (PAPA).
Conclusions: There is a place in both research and clinical settings for a rigorously operationalized interview (such as the
CAPA) that focuses on ensuring that respondents understand what is being asked and on clearly defining levels of symptom
severity and functional impairment. J. Am. Acad. Child Adolesc. Psychiatry, 2000, 39(1):39-48. Key Words: child and adolescent psychiatry, assessment, psychiatric interview, Child and Adolescent Psychiatric Assessment.
The Child and Adolescent Psychiatric Assessment (CAPA)
is an interviewer-based structured psychiatric interview
that collects data on the onset dates, duration, frequency,
and intensity of symproms of a wide range of psychiatric
diagnoses (Table 1) according to DSM-IV DSM-III-R, or
ICD-10 criteria. It provides a structure for the mind of the
interviewer. The interview serves as a guide in determining
whether a symptom is present; the interviewer makes that
decision on the basis of information collected from the
patient or respondent. Detailed definitions of symptoms
are provided, so we refer to the CAPA as being “glossarybased” (Angold and Fisher, 1999). The interviewer is expected to question until he or she can decide whether a
symptom meeting each definition is present.
The CAPA is in modular form, so that particular sections can be used separately from the rest of the interview.
The diagnostic section is part of an integrated package
AcceptedAugust IZ 1999.
From the Centerfor DeuelopmentalEpidemiology, Department of Psychiatry
and BehaviorafSciences, Duke Uniuersiq Medical Centec Durham, NC
This work was supported by NIMHgrantMH48085. Additional support was
provided through a grantfiom the William T Grant Foundation.
Reprint requesh to DI:Ango& Depament of Psychiatry and Behavioral Sciences,
Box 3454, Duke UniuersiqMedical Centec Durham, NC27710; e-mail address:
adrian.angoU@duke.edu.
0890-8567/00/3901-003902000 by the American Academy of Child
and Adolescent Psychiatry.
J . A M . A C A D . C H I L D A D O L E S C . PSYCHIATRY, 39:1, J A N U A R Y 2000
that also covers sociodemographic data, family structure
and functioning, peer and adult relationships (Angold
et al., 1999b))the assessment of life events (Costello et al.,
1998a))and ratings of psychosocial impairment resulting
from psychiatric symptomatology (Angold et al., 1999b).
Companion measures cover service use for mental health,
barriers to care, and the impact of child mental illness on
the family (Ascher et al., 1936; Farmer et al., 1994; Messer
et al., 1996).
DESCRIPTION OFTHE CAPA
Figure 1 shows a typical page of the CAPA. In the lefthand column (labeled 1) are the name and a brief description of the symptom as a reminder to the interviewer
(much fuller definitions are given in the glossary), followed by mandatory probes (labeled 2 and emphasized in
boldface type and with an asterisk) and discretionary
probes (labeled 3). The middle column contains coding
rules and directions (labeled 4, 5, 6), and the code boxes
completed by the interviewer are on the right (labeled 7).
A full description of the development and structure of the
CAPA can be found in 2 earlier reports (Angold et al.,
1995; Costello et al., 1998a).
The Primary Period
The CAPA focuses on the 3 months immediately preceding the interview-this is called the primay period.
39
A N G O L D A N D COSTELLO
TABLE 1
Summary of the Properties of the CAPA and Its Congeners
Age range and informants
CAPA
YAPA
PAPA
Type of interview
Interviewer qualifications
Languages available
Diagnostic system
Diagnoses covered
Disruptive behavior disorders
Mood disorders
Anxiety disorders
Eating disorders
Sleep disorders
Elimination disorders
Substance uselabuseldependence
Tic disorders
Other
9-17; index child and parent
18+ ; index participant
3-6; parent
Interviewer-based; glossary-based
Bachelor-level degree and up
English, Spanish; training may also be provided in English for administration of
the CAPA in other languages
DSM-IK DSM-III-R, ICD-10
Attention-deficitlhyperactivitydisorder; conduct disorder; oppositional defiant
disorder; delinquency; antisocial personality disorder"; disruptive behavior
disorders NOS
Major depression; dysthymia; minor depression; mixed anxiety-depressive
disorder; depression NOS; mania"; hypomania"
Generalized anxiety disorder; overanxious disorderb; separation anxiety disorderb;
panic disorder; agoraphobia; social phobia; specific phobias; avoidant disorderb;
obsessive-compulsive disorder; elective mutism
Anorexia nervosa"; bulimia nervosa"; ruminationb; early childhood eating
difficultiesb;food fadsb
Primary insomnia; primary hypersomnia; nightmare disorder; sleep terror disorder;
sleepwalking disorder; bedtime problemsb
Encopresis; enuresis; constipation
Tobacco"; alcohol"; cannabis"; cocaine/crack"; amphetamines"; barbituratesQ;
hypnotics/sedatives"; LSD"; phencyclidine"; opioids" (modules also available for
a number of substance-related deliria and hallucinoses)
Phonic tic disorders; motor tic disorders; Tourette's disorder
Schizophrenia and other nonaffective psychotic disorders; posttraumatic stress
disorder; adjustment disorders; trichotillomania; somatization symptoms;
reactive attachment disorder of childhoodb
Note: CAPA = Child and Adolescent Psychiatric Assessment; YAPA = Young Adult Psychiatric Assessment; PAPA =
Preschool-Age Psychiatric Assessment; NOS = not otherwise specified.
" Not included in PAPA.
Not included in YAPA.
Information is also collected on some symptoms involving infrequent discrete acts, such as firesetting or suicide
attempts, that occurred outside the primary period. Three
months was chosen because of concerns about the reliability of memory for longer periods, which are now supported by data showing that the reliability of recall of
dates of onset of symptoms falls off very rapidly after 3 to
5 months in both parents and children (Angold et al.,
1996), and descriptions of children's particular difficulties
with questions concerning dates and timing in the Diagnostic Interview Schedule for Children (DISC) (Breton
et al., 1995).
Training and coding are based on a detailed glossary,
which defines each symptom and the criteria for coding
different levels of symptom severity on several dimensions.
Age Range and Informants
Intensity
Child self-report and parent report versions of the CAPA
are available. Both cover very much the same material,
except that symptoms of attention-deficitlhyperactivitydis-
Intensity refers to the strength or force of the symptom
itself,without consideration of features such as frequency or
duration. For the most part, the intensity of each symptom
40
order (ADHD) is reported only by parents, because we, like
others, have found that child self-reports of ADHD symptoms are not very usefd for diagnostic purposes. The child
self-report interview is suitable for use with children aged 8
to 9 and upward to young adulthood. Special versions of
the interview (see below) are available for use with younger
children and young adults.
CAPA GLOSSARY
J . A M . ACAD. C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 1 , JANUARY 2000
CAPA
or behavior is scored on either a 3-point or a 4-point scale
(for example, see 4 in Fig. 1; 0 indicates that the symptom
is absent and 1 reflects uncertainty about the presence of
the symptom, resulting in a 4-point coding). The intensity
criteria differ somewhat by symptom type. The first group
of symptoms consists of those intrapsychic phenomena
that are normal when present to a lesser degree (such as
worrying) so that their pathological status is largely a qmnCoding rules
efinitions and auestions
Codes
COMPULSIONS
COMPULSIONS
Repetitive, purposeful, and intentional acts associated
with a subjective feeling of compulsion arising within the
subject and not forced by any external power or agency,
performed despite being regarded as excessive,
unreasonable, pointless, or absurd.
*Do you have to check things more than other people7
2 = Compulsions intrusive into at least 2
activities and are at least sometimes
uncontrollable
3 = Compulsions intrusive into most
activities and are almost always
uncontrollable
HOME
*Are there any things that you feel you have to do?
*like touching things in a certain way?
*Or washing over and over again?
+@
SCHOOL
+@
*Do you spend a lot of time putting things in a special
order?
ELSEWHERE
'Or arranging things so that they are just right?
*Do you have any routines or rituals that you have to
do?
What would happen if you didn't do it?
What then?
What are you afraid will happen?
Do you feel uncomfortableif you don't "do compulsion"
just right?
Are you worried about dirt or germs?
Q
What do you do about it?
*Why do you do it?
What makes you do it?
How long do you do it for?
When did it start?
Do you try not to do it?
-
RESISTANCE
2 Subject tries to resist performing
the compulsiveact at least sometimes
3 = Subject usually tries to resist
IF A CLEAR EXTERNAL FORCE IS REPORTED AS
BEING THE MOTIVATOR OF COMPULSIVE
BEHAVIOR, CODE UNDER DELUSIONS AND
DELUSIONAL INTERPRETATIONS( PSYCHOSIS
SECTION).
Fig. 1 A sample page from the Child and Adolescent PsychiatricAssessment (CAPA).
1. A M . A C A D . C H I L D A D O L E S C . PSYCHIATRY, 39:1, JANUARY 2000
41
A N G O L D A N D COSTELLO
titative matter. For these items a symptom’s intensity is
usually evaluated according
- to 3 dimensions: (I) its intrusiveness into other mental activities; (2) its lack of mod#iability, or the child’s inability to modify the phenomenon by
action, thought, behavior, or environmental manipulation
(as when a depressed child fails to cheer herself up by going
out to play with her friends); (3) its generalization, that is
the degree to which symptomatic thoughts or emotions are
present across a range of activities that may be quite unrelated to the content of the symptom (as in the case the child
who feels afraid of parental separation in situations in
which separation is not threatened).
The second group of symptoms comprises those with
qualitative characteristics that define the symptom whenever it occurs. This applies to most psychotic phenomena, but the group also includes items such as firesetting,
stealing, and tics. Here various configural and frequency
characteristics are relevant (e.g., the type and frequency
of tics or the nature of delusions).
The third group of symptoms comprise conduct disturbances, such as disobedience, that are abnormal only
when they are frequent and associated with a negative
response to admonition. Sometimes the intensity threshold
is implicit in the form of the symptom (for instance, tantrums are defined in terms of attempted violence against
people or property), but it is ofien necessary to require
generalization across activities, in order to set a threshold.
In the case of antisocial behavior, 3 additional features are
recorded: (1) Directedness-whether the behavior was
directed against common property (as in vandalizing a telephone box), persons unknown or property not belonging
to a previously identifiable person or persons (as in stealing the car of unknown owner), or a specific person or
persons (as in smashing an enemy’s bicycle); (2) Solitary/
Accompanied-whether the activity was performed alone
or in company; and (3) Setting (also recorded for ADHD
and obsessive-compulsive disorder symptoms; see, e.g.,
5 in Fig. 1).
Time-Related Severity Ratings
Several time-related indices of symptom severity may
be specified (see, eg., 7 in Fig. 1): (1) duration of bouts
or episodes of the symptom (these ratings apply only to
symptoms whose duration is clinically meaningful, such
as abnormal moods); (2) frequency of bouts or episodes
of the symptom; and (3) length of time the symptom has
been occurring (i.e., the time elapsed since the onset of
the symptom).
42
Psychosocial Impairment Related to the Presence of the
Symptom (Incapacity)
Psychosocial impairment secondary to psychiatric
symptomatology is rated in 19 domains of functioning
related to life at home, at school, and elsewhere. In general,
some decrement in actual function has to be described for
a positive rating to be given (Angold et al., 1995). Having
completed the symptom part of the interview, the interviewer reviews with the subject the areas of positive symptomatology. For positive symptom areas the subject is
questioned about whether those symptoms had resulted in
impairment in any domain. There is no requirement that
symptoms in any group should meet diagnostic criteria, so
impairment resulting from “subthreshold symptoms can
be coded (see, e.g., Angold et al., 1999b). In the case of
impairments in human relationships it is also possible to
code a “pure” impairment unrelated to symptoms of psychiatric disorders, thus permitting the diagnosis of certain
DSM-IV V codes such as parent-child relational problem.
CONDUCT OF THE INTERVIEW
CAPA Probes
Interviewees are allowed to answer questions in their
own words and to describe their experiences and behavior
in their own way. Once a symptom has been thoroughly
investigated, all the information obtained is used to match
the behavior, emotion, or thought described by the subject to appropriate glossary definitions and levels of severity. It is especially important to elicit detailed descriptions
and examples of symptoms. The CAPA provides a set of
formal rules for the use of screening, mandatory, and discretionary questions. Most other interviewer-based interviews provide specified questions, but few or no formal
rules about when they are to be used or skipped.
A detailed series of probes is provided for each item,
and here the CAPA uses a combination of the specific
question structures characteristic of respondent-based
interviews and the clarification techniques of interviewerbased interviews. There are 3 levels of probe: First, there
are screening questions, which serve as entry points to
groups of items that are based on a single key phenomenon. The many rated characteristics of depressed mood
are, for instance, obviously dependent on the presence of
depressed mood. All screening questions are asked verbatim unless the subject has already provided the necessary
information in response to previous questions. It is
important to be sensitive to the subject‘s level of under-
]. A M . ACAD. C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 1 , JANUARY 2 0 0 0
CAPA
standing in questioning throughout the interview, and it
may be necessary to modify the wording of questions for
particular individuals.The aim is to encourage children to
think hard about their experiences rather than providing
glib yeslno answers.
Once a symptom area has been begun, 2 levels of
probes are provided for each individual rating: (1) Mandatoyprobes (see, e.g., 2 in Fig. 1) are questions that must
be asked of all subjects who enter the section unless the
information has already been provided. (2) Dircretionay
probes (see, e.g., 3 in Fig. 1) are suggested additional questions that provide guidance for the clarification process.
Open questions that leave room for description of emotions
and behavior are widely used, and interviewer training
strongly emphasizes the development of a conversational
probing style, avoiding barrages of closed questions. Studies
of the provision of child psychiatric information by parents have concluded that the greatest amount of factual
information was collected by combining a systematic
approach with open questions (Cox et al., 198la,b; Rutter
et al., 1981). This approach also facilitates the important
task of reconciling any discrepancies in the information
provided at different points during the interview. However,
closed questions are absolutely necessary to elicit information that is otherwise not forthcoming.
Observations of Interview Behavior
The final section of the CAPA consists of ratings of 67
glossary-defined items of observable behavior, completed
by the interviewer at the end of the interview. They cover
(1) level of activity and abnormalities of motor behavior,
(2) the child’s apparent mood state, (3) the quality of the
child’s social interaction during the interview, and (4)
psychotic behavior.
The cost of training depends on the number of CAPA
modules being used and the number of trainees, but for
the full CAPA typically comes to approximately $600 per
trainee plus $2,000 fixed costs. When several interviewers
are to be trained it is usually more cost-efficient for them
to remain at their home site and for a CAPA trainer to
spend 2 of the 4 weeks of training with them.
Making a Diagnosis From a CAPA Interview
Once the interview and its coding have been completed, data are entered into a customized computer database that can be easily modified to suit the requirements
of a particular study or clinical setting. Computerized
algorithms, written in SAS, generate diagnoses for DSMZZZ,DSM-ZV and ZCD-10, and a variety of symptom,
impairment, life events, and family functioning scale
scores. The diagnostic algorithms do not use items from
the interviewer observations sections of the interview.
RESEARCH ON THE PERFORMANCE OFTHE CAPA
Data described in this section come from the Great
Smoky Mountains Study (GSMS) and the Virginia Twin
Study of Adolescent Behavioral Development (VTSAl3D) .
The GSMS is a longitudinal study of a representative sample of children and adolescents living in a predominantly
rural area in the southern Appalachians. In a sample of
1,420 youths aged 9 to 13years at intake, parents and children have been interviewed annually since 1993 (4 waves
of interviews are considered below) using the CAPA. The
VTSAl3D is a large longitudinal study of approximately
1,500 pairs of juvenile twins that used the CAPA to assess
DSM-ZZZ-R psychopathology. Full details of the design of
these studies can be found in earlier reports (Costello et al.,
1996; Eaves et d., 1997).
Interviewer Selection and Training
Trainees have included psychiatrists, psychologists,
social workers, nurses, and graduate- and bachelor’s-level
personnel with little or no previous clinical experience.
The principal requirement for C M A interviewers is that
they can abide by the structure provided by the interview,
while showing sensitivity and intelligence in getting
descriptions of behavior. Training requires 1 to 2 weeks
of classroom work and 1 to 2 weeks of practice. Didactic
training on the glossary and interview methods is interspersed with role-playing, taped and live interviews, and
feedback. Certification by a qualified CAPA trainer is
required before using the CAI’A in the field.
J. AM. ACAD. C H I L D A D O L E S C . PSYCHIATRY, 39:1, JANUARY 2 0 0 0
Time Taken by the Interview
Table 2 shows the average time taken by the parent
and child versions of the 2 major components of the
CAPA across nearly 6,000 parent and child interviews.
The first row consists of the psychiatric symptoms and
measures of psychosocial impairment (roughly the equivalent of the contents of the DISC, for example).The second row relates to the CAPA’s additional sections on
family structure, family functioning, and basic demographics, including family income. O n average, an additional 45 minutes is required in the office for completing
interview coding and 30 minutes needs to be set aside for
43
A N G O L D A N D COSTELLO
TABLE 2
Areas Covered and Average Time Taken by Major Sections of the
Child and Adolescent Psychiatric Assessment
Parent
Section of the Interview
Syrnptomatology and
functional impairment
Family structure, functioning,
and resources
Total
Child
Mean
Range
Mean
Range
46
10-150
39
12-120
20
66
10-60
20-210
20
10-30
22-150
59
Note: Data from the Great Smoky Mountains Study, 4 waves.
Values represent minutes.
supervisor review. Data entry from a complete CAPA
takes about 25 minutes.
Reliability
In a study of the CAPA’s test-retest reliability with 77
clinically referred children aged 10 to 16 years, K values
for diagnosis were 0.9 for major depression, 0.85 for dysthymia, 0.74 for overanxious disorder, 0.79 for generalized anxiety disorder, 0.55 for CD, and 1.0 for substance
abuse/dependence. Intraclass correlation coefficients for
DSM-111-R symptom scale scores ranged from 0.5 for
oppositional defiant disorder (ODD) to greater than 0.90
for posttraumatic stress disorder and substance abuse/
dependence (Angold and Costello, 1995; Costello et al.,
1998a). The intraclass correlation coefficient for level of
psychosocial impairment by child self-report was 0.77
(Angold and Costello, 1995). No test-retest reliability data
on the interviewer observations section are available.
Attenuation, the fall in numbers of symptom reports at
the second interview, so familiar from studies of the DISC
(Jensen et al., 1995),was significant only for CD symptoms.
Individuals who reported fewer C D symptoms in the second interview than in the first were much more likely
than those who did not show attenuation to have reported
the symptom of o j e n telling lies in the first interview. Angold
and Costello (1995) concluded from this that thefirst
interview was, therefore, likely to represent a truer picture.
Validity
The problem with trying to assess the validity of psychiatric interviews is that there is no noninterview test for
most psychiatric disorders. The structured interview itself
has become the closest approximation we have to a “gold
standard.” So how are we to “validate” the diagnoses
obtained from such interviews?This is a version of a very
44
old problem in psychology, one that led to the concept of
construct validity. The key idea is that the validity of an
instrument for the measurement of a psychological construct inheres not in some single agreement coefficient
with one external standard, but in the instrument’s performance within the nornologicdl net of theory and empirical data concerning the construct or constructs that that
instrument purports to measure (American Psychological
Association, 1985; Anastasi, 1986; Cronbach and Meehl,
1955; Jenkins, 1946; Wallace, 1965; Weitz, 1961). As
Gulliksen (1950) remarked, “at some point in the advance
of psychology it would seem appropriate for the psychologist to lead the way in establishing good criterion measures,
instead of just attempting to construct imperfect tests for
attributes that are presumed to be assessed more accurately
and more validly by the judgment of experts” (p. 511).
Structured interviews were developed because of the
poor psychometric properties of unaided clinical diagnosis, so comparisons with clinical judgment are a flawed
test of diagnostic interview validity. In considering the
validity of the CAPA, we take a construct validation
approach and describe what we currently know about the
CAPA in relation to 10 aspects of the nomological net
pertaining to child and adolescent psychiatric diagnosis:
1. Are diagnostic rates and age andgenderpatterns of disorder given by the CAPA consistent with those found using
other interviews? Diagnostic studies suggest that approximately 20% of individuals in late childhood or adolescence have a psychiatric disorder in any 6-month to
1-year period. The CAPA should identi@somewhat fewer
than 20% of children at any one assessment, because it
covers a primary period of only 3 months. This is exactly
what we found in the GSMS (Costello et al., 1996); over
4 years of annual interviews the average 3-month prevalence was 13.3%.
We should expect the CAPA to allocate diagnoses of
rare disorders rarely and of common disorders commonly. Depression (3.9%) and anxiety disorders (3.3%)
had the highest prevalence, followed by C D (2.6%),
O D D (1A%), and ADHD (1.2%). Rarer disorders were
rarely diagnosed, e.g., obsessive-compulsive disorder
(O.2%), mania (O.1%), bulimia (O.I%), and schizophrenia (0.1%). All of these rates fall within the expected
population prevalence ranges for the individual disorders
in this age group (Angold et al., 1999a). If we consider
serious emotional disturbance (diagnosis accompanied
by significantly impaired functioning), the 3-month rate
of 4.4% generated by the CAPA is consistent with 6-
J . A M . ACAD. C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 1 , JANUARY 2 0 0 0
CAPA
month to l-year rates of 5.2% to 7.4% found in other
studies (Costello et al., 1998b).
CAPA interviews in the GSMS mirror clinical and
research experience in diagnosing anxiety disorders more
often in girls, and CD, substance abuse, and ADHD more
often in boys, as shown in Figure 2. All these differences
were significant ( p < .01) except for that involving ODD,
which other studies have also found to occur only slightly
more commonly in boys (Lahey et al., in press) (see also
Costello et al., 1996). CAPA-diagnosed depression only
becomes more common in girls than boys in mid-puberty
(Angold et al., 1998).ADHD prevalence rates, as expected,
fell substantially with increasing age (from 3.1 % at age 9 to
0.14% at age 16).Hence the relatively low overall 3-month
prevalence referred to above.
2. Are patterns of diagnostic comorbidity consistent with
thosefound by other interviews?An extensive review of the
4.5
YO of girls with diagnosis
YO of boys with diagnosis
3.6
.v)
v)
M
2.7
m
5
t
'S
52 1.8
2
0.9
0
I
-
Anxiety
Conduct
1 Substance abuse 1
ODD
ADHD
Fig. 2 Gender ratios for individual diagnoses in the Great Smoky Mountains
Study. ODD = oppositional defiant disorder; ADHD = attention-deficit/
hyperactivity disorder.
J. AM. A C A D . CHILD A D O L E S C . PSYCHIATRY, 3 9 : 1 , JANUARY 2000
comorbidity literature revealed that patterns of comorbidity reported with other instruments are mirrored in studies
using the CAPA (Angold et al., 1999a).
3. Are symptomatic diagnoses associated with psycbosocial
impairment?Diagnosed children were at increased risk for
impaired functioning at home, at school, and with peers.
In accord with clinical experience, impaired functioning
was more conspicuous in children with disruptive behavior disorders (odds ratio [OR] = 7.6) than in children with
anxiety or depression (OR = 4.3).
4. Are parent and child reports of psychopathology on the
CAPA rekted to parent and teacher reports of problems on
well-established scales for detecting psychopathology? In the
GSMS the externalizing items of the Child Behavior
Checklist (Achenbach, 1991) were used as a screen to
oversample individuals for CAPA interviewing. In the 4
years following the screening questionnaire, rates of externalizing diagnoses from the W A were 4.5 times higher
in the screen-high group than in the screen-low group
(9% versus 2%).
The GSMS collected data from teachers using the
Teacher's Report Form (TRF) (Achenbach and Edelbrock,
1986). The mean 3-wave TRF score for those who never
met criteria for a diagnosis was 12.8, compared with 19.9
for those with a diagnosis but without impairment ( p =
.OOOS) and 32.3 for those with both diagnosis and impairment ( p < .OOO1 for comparison with no diagnosis andp =
.0009 for comparison with diagnosis alone).
5. Do children with CAPA-identified disorders use more
mental health services? A crude measure of the validity of
CAPA symptom ratings is provided by the association
between levels of CAPA DSM-111-R symptomatologyand
the probability of having used specialty mental health services during the 3 months preceding the interview. Averaging across the whole range of symptom scores, using
hierarchical mixed-effects logistic regression, each addtional
DSM-111-R symptom was associated with a 10% increase
in the odds of having received specialty mental health services during the preceding 3 months ( p < .0001) (Fig. 3).
6 Do WA-diagnosed children tend to comefiom families with a histoy of mental illness? Family history of mental illness is one of the strongest predictors of psychiatric
disorder in children, although the specificity of links
between particular disorders across generations remains in
doubt. Across 4 waves of GSMS, children with a family
history of treated mental illness were 3 times as likely to
have diagnoses of anxiety or depressive disorders (10.7%
versus 3.1%), while those with a family history of crime
45
A N G O L D A N D COSTELLO
lor
those with no diagnosis at the first assessment (risk ratio
6.4). There was also a high degree of diagnostic specificity
in that continuity (Fig. 4), with risk ratios ranging from
7.4 for depression to 31.4 for substance abuse.
9. Do CAPA diagnoses predict negative 1;fe outcomes?
35 -
8
v
Child and adolescent psychiatric disorders are strong predictors of serious negative life outcomes such as school
dropout, expulsion from school, teen pregnancy, and
arrests. In the GSMS data 14% youths with a diagnosed
disorder, compared with only 1% of children without a
diagnosed disorder, experienced one or more of these
events (OR = 12.0). These negative events were, as
expected, much more highly associated with behavioral
diagnoses (OR = 36.3) than with anxiety or depression
(OR = 2.0).
10. Do W Ainterviewer observations rehte meaningfdy
to reported diagnosis and treatment?Two findings suggest
that at least some of the CAPA interviewers' ratings of
'E3 3 0 5
-
c 25(d
%E 20x
70 r
Diagnosis present last year
Diagnosis absent last year
I 3 t o 5 I 9 t o 1 1 I 1 5 t o 1 7 I >20
Oto2
6to8
12to14 18to20
Number of symptoms
6.4
Fig. 3 Relationship between DSM-IIZ-R symptom counts and service use in
the Great Smoky Mountains Study.
7.9
13.4
or drug problems were almost twice as likely to have a
behavioral diagnosis (9.0% versus 5.1%).
ZIs there agenetic hadingfor the diagnosis?Monozygotic
twins in the VTSABD were more concordant than dizygotic twins for ADHD, CD, ODD, separation anxiety,
overanxious disorder, and depression (Eaves et al., 1997;
Topolski et al., 1997). In many ways the appearance of
genetic effects in twin studies is particularly convincing
evidence that a test measures a real construct, because heritability estimates depend on patterns of correlation
between pairs of individuals rated by different interviewers, and so they cannot be the result of interviewer
halo effects. The fact that different disorders, as measured
by the CAPA, show rather different patterns of genetic and
environmental effects offers evidence of divergent validity.
8. Are W A diagnoses consistent over time? Many child
and adolescent psychiatric disorders are chronic or recurrent, so we expect to see some continuity in diagnosis over
time. In the GSMS 48% of youths with a diagnosis at one
assessment had one a year later, compared with 7% of
46
26.5
14.8
7.4
"
1 CDlODD 1 Anxiety 1 SED 1
Substance abuse ADHD
Depression
Any Dx
Fig. 4 Diagnostic continuity in the Great Smoky Mountains Study (figures
above bars are odds ratios for comparisons between those with and those
without a diagnosis in the preceding year). C D = conduct disorder; O D D =
oppositional defiant disorder; A D H D = attention-deficit/hyperactivity disorder; SED = serious emotional disturbance; Dx = diagnosis.
J . A M . ACAD. C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 1 , JANUARY 2 0 0 0
CAPA
intrainterviewbehavior are useful. First, interviewer ratings
of overactivity and inattention during the interview are
strongly related to parent-reported hyperactivity (note that
here the interviewer rating the behavior is blind to the
parental reports). In the GSMS, of children whose parents
never reported them to have impairing ADHD symptoms at any of the 4 interview waves, 12% were observed
to be overactive or inattentive during at least one of the
interviews. Of those who met full DSM-III-R ADHD
criteria by parent report, 52% were noted to have been
overactive or inattentive during one of their CAPA interviews. Of those reported to have impairing subthreshold
DSM-III-RADHD symptoms, 46% were noted to have
been observably overactive or inattentive. A substantial
group of children whose parents never reported them to
have impairing A D H D symptoms had nonetheless
received stimulant medications; half of these treated children were rated as being overactive or inattentive by interviewer observation. In addition, interviewer ratings of the
presence of observed tics (a well-known side effect of
stimulant medications) were much more common in children currently being treated with stimulants than in the
same children when they were not taking stimulants.
(Angold and Costello, unpublished).
DEVELOPMENT OF THE CAPA FOR SPECIAL
PURPOSES
Twin CAPA
A special version of the CAPA was developed for the
VTSABD (see above). This version is streamlined in the
symptom area to make it easier to conduct interviews
about multiple children with both parents. It also contains
a lifetime assessment of psychopathology based on CAPA
interviewing principles (Eaves et al., 1997; Simonoff et al.,
1997).
Young Adult Psychiatric Assessment
The Young Adult Psychiatric Assessment (YAPA) is a
modification of the CAPA that is suitable for use with
young adults. It provides a focus on diagnoses, living situations, relationships, and areas of functioning relevant to
this age group.
Preschool-Age Psychiatric Assessment
The Preschool-Age Psychiatric Assessment (PAPA), a
parent report-only version focused on children aged 3 to
6 years, is currently being developed. This version
excludes symptoms of little relevance to younger children
and has additional items pertinent to younger children’s
behavior.
Spanish CAPA
Glorisa Canino, Ph.D., and her highly experienced
multinational team of translators are currently preparing
a multidialect Spanish version of the CAPA.
Gatekeeper CAPA
Computerization of the CAPA
We have experimented with the use of a shorter “gatekeeper” interview approach to some major problem areas
(anxiety, depression, CD, and ODD). A subset of key
items was covered at the beginning of the interview, and
the rest of the section was completed only by those with a
positive response to gatekeeper questions. The rest of the
diagnoses were treated as usual. The gatekeeper approach
saved about 11 minutes on the parent interview and about
20 minutes on the interview with the child (times refer to
the symptomatology and impairment sections of the
interview). The shorter interview affected the number of
diagnoses generated by the interview in only 1 out of 9
diagnosis-by-age comparisons: 12-year-olds reported significantly fewer C D diagnoses with the gatekeeper than
with the standard interview. In the other 8 comparisons
the numbers of diagnoses were not significantly different
and there was no particular trend for the gatekeeper interview to result in fewer diagnoses.
J . A M . ACAD. C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 1 , JANUARY 2 0 0 0
An audio computer-administered version for selfreports in the substance use, abuse, and dependence section of the CAPA is currently in use. A
computer-assisted version of the whole interview is currently under experimental development.
CONCLUSIONS
Clinical and Community Research Uses of the CAPA
It is probably fair to say that clinicians do not enjoy
doing respondent-based interviews very much because the
questions they can ask are so highly constrained. They
may not be convinced that the child understood the question, but if they add their own questions then the advantages of using a respondent-based interview are lost,
because an unstructured component has been added. On
the other hand, training on an interviewer-based interview is usually of interest to clinicians because it raises a
47
A N G O L D A N D COSTELLO
host of issues about interviewing style and strategy that
few have had time or encouragement to think through
during their training. Thus, interviewer-based interviews
may be particularly suitable for use in clinical assessments,
and the CAPA has been used in several clinical and treatment studies. Given the fact that well-trained and supervised Lay interviewers can produce reliable ratings of
symptoms and diagnoses, lay-administered CAPAs can
also be used in the initial evaluation of children and adolescents presenting for clinical services.
When it comes to general population studies, there has
been more debate about the place of interviewer-based
instruments. However, the development of detailed glossaries and training manuals now makes it perfectly possible
to train “lay” interviewers adequately and to achieve levels
of reliability as good as those found with respondent-based
interviews. Some of the largest ongoing general population
studies are using interviewer-based instruments, including
the CAPA (Burns et al., 1995; Costello et al., 1996; Eaves
et al., 1997; Lewinsohn et al., 1993; Simonoff et al., 1997).
Some people are concerned about the relative costs of
training and quality control between interviewer-based
and respondent-based interviews, but when we compared the cost per subject interviewed, using figures from
recently hnded NIMH studies, we found the cost differential small or nonexistent. At the present time, it seems
that decisions about whether to use an interviewer-based
interview in any type of study or clinical application
should be made on the basis of which interview collects
the information best suited to answering the questions
being asked.
USER INFORMATION
An extensive CAPA information packet is available
from the first author. At the time of writing this includes
interview schedules and the glossary plus details of the
CAPASpsychometric performance at a cost of $50.
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