The Assessment Checklist for Adolescents — ACA: A scale for measuring the mental health of young people in foster, kinship, residential and adoptive care

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Abstract

The Assessment Checklist for Adolescents — ACA is a 105-item carer-report mental health rating scale, measuring behaviours, emotional states, traits, and manners of relating to others, as manifested by adolescents (ages 12 to 17) residing in various types of alternate care, as well as those adopted from care. The ACA was designed for population and clinical research with these young people, and for use as a clinical assessment measure. The ACA's content was largely derived from the Assessment Checklist for Children (ACC). Fifteen ACC items were modified to better reflect adolescent difficulties, and 25 additional items were derived using a combination of inductive and deductive strategies. Item and factor analyses were carried out on scores from a 136-item research instrument, obtained for 230 young people residing in long-term care (as part of the NSW Children in Care study). These data were supplemented by ACC scores obtained for 142 adolescents residing in treatment foster care in Ontario, Canada. A robust 7-factor model was identified among a core of 73 clinical item scores, accounting for 51% of score variance. Four of the factors replicate ACC clinical scales (non-reciprocal interpersonal behaviour; sexual behaviour problems; food maintenance behaviour; and suicide discourse), and three are unique to the ACA (social instability/behavioural dysregulation; emotional dysregulation/distorted social cognition; and dissociation/trauma symptoms). The ACA also contains two empirically-derived low self-esteem scales (low confidence; negative self-image) that are shared with the ACC. Initial data indicate that the ACA has good content, construct and criterion-related validity, as well as high internal reliability.

Highlights

► The Assessment Checklist for Adolescents (ACA) is a carer-report mental health scale. ► The ACA measures the mental health of adolescents in care, and adopted from care. ► The ACA's content is largely derived from the Assessment Checklist for Children. ► The ACA has 7 empirically-derived attachment- and trauma-related clinical scales. ► The ACA has good content and construct validity, and high internal reliability.

Introduction

The present paper describes the development of the Assessment Checklist for Adolescents (ACA), which is an adolescent version of the Assessment Checklist for Children (ACC). The ACC is a 120-item carer-report psychiatric rating instrument, that measures behaviours, emotional states, traits, and manners of relating to others, as manifested by children in care, and related populations (including children adopted from care) (Tarren-Sweeney, 2007). It was designed to measure a range of mental health difficulties observed among children in care that are not adequately measured by standard rating instruments, such as the Child Behaviour Checklist (CBCL), the Strengths and Difficulties Questionnaire (SDQ) and the Conners scales. These consist of a number of attachment-related difficulties (indiscriminate, non-reciprocal and pseudomature types), insecure relating, trauma-related anxiety, abnormal responses to pain, overeating and related food maintenance behaviours, sexual behaviour problems, self-injury and suicidal behaviours and discourse. The ACC was developed a decade ago for use in the Children in Care Study (CICS), a prospective epidemiological study of the mental health of children in long-term foster and kinship care, in New South Wales (NSW), Australia (Tarren-Sweeney & Hazell, 2006). Aside from investigating the nature of the mental health of children in care, the CICS located evidence that pre-care social adversity factors (notably the extent of children's exposure to pre-care maltreatment) were stronger predictors of the mental health difficulties measured by the ACC, than were children's experiences in care. Since then, the ACC has been employed in over 20 studies in Europe, North America and Australasia, and is increasingly used as a clinical assessment tool by specialised mental health services for children and young people in care — particularly in Britain and Australia (Chambers et al., 2010, DeJong, 2010).

Prior to commencing the CICS, the ACC's content was derived for a wide age range (4 to 17 years), with a view to: 1. employing a single set of items for baseline and follow-up studies; and 2. comparing the factor structure of this common set of items at different developmental stages. This plan was subsequently revised following examinations of what the ACC appears to measure among children and young people at different ages, and with different developmental pathways. A developmental perspective suggests that clinical phenomena are likely to evolve in complex ways in the context of both age-sensitive developmental stages, and maladaptive developmental trajectories. For this reason it was thought that, prior to embarking on a 7- to 9-year follow-up of the CICS cohort (who would then be aged 11 to 18 years), there should be closer investigation of the validity and comprehensiveness of the ACC item pool for measuring those mental health symptoms manifested by adolescents in care that are not adequately measured by the CBCL, SDQ, Conners, etc. This preliminary investigation located a number of items that appear unsuitable for an adolescent population; suggested a need to modify some ACC items for an adolescent population; and suggested that some clinical phenomena manifested by young people in care are not adequately captured by the ACC. These findings prompted the formal development of an adolescent-specific measure for young people in the care system — the Assessment Checklist for Adolescents.

Section snippets

Selection and refinement of ACA content

The central strategy for selecting and developing item content for the ACA was to refine and build on the content development carried out for the ACC a decade previously, rather than devise content from scratch. Prior to its inclusion in the CICS baseline survey, the ACC's clinical content was systematically derived using a combination of deductive and inductive strategies (Tarren-Sweeney, 2007), with the aim of identifying all clinically significant problems experienced by children and young

Checklist format

The ACA administration format is identical to the ACC. Each item refers to an individual behaviour, emotional state, trait, or manner of relating to others, that is observable by a child's carer. There are separate versions for boys and girls, allowing for use of gender-specific personal pronouns (him/her, himself/herself, he/she). Items are otherwise identical for boys and girls.

Sample

Item and factor analyses were performed on ACA scores for 372 young people in long-term alternate care, obtained from the CICS follow-up survey (n = 85) and the CICS adolescent survey (n = 147). Some analyses were supplemented by de-identified ACC scores for 142 young people enrolled in the multi-agency treatment foster care programme of the Children's Aid Societies of Durham, Highland Shores and Kawartha-Haliburton, in Ontario, Canada. The CICS is a prospective, epidemiological study of the mental

Scale construction

Clinical and low self-esteem scales were derived from items with factor loadings above .40 on the relevant 7-factor and 5-factor clinical models, and the 2-factor low self-esteem model. Surprisingly, no item loaded above .40 on more than one factor. An additional criterion was that an item's presence should not lower the internal consistency of a scale. Seventy two items met criteria for inclusion with a clinical scale. Fifteen items that were considered clinically important but did not meet

Scale properties

The clinical scales are labelled:

  • I.

    Non-reciprocal interpersonal behaviour

  • II.

    Social instability/behavioural dysregulation*

  • III.

    Emotional dysregulation/distorted social cognition*

  • IV.

    Dissociation/trauma symptoms*

  • V.

    Food maintenance

  • VI.

    Sexual behaviour

  • VII.

    Suicide discourse

The low self-esteem scales are labelled:

  • I.

    Negative self-image

  • II.

    Low confidence

*Scale is unique to the ACA.

Content validity

The ACC's content was derived systematically over several years, with a view to identifying clinically significant behaviour manifested by 4 to 16 year-old children in foster, residential and kinship care that is not adequately measured by the CBCL (Tarren-Sweeney, 2007). Further to this, a systematic process was pursued to identify additional adolescent-specific mental health difficulties manifested by young people in care, using a similar combination of inductive and deductive strategies,

Discussion

The development of the ACA was hampered by a small sample size for deriving factors from such a large item pool. A number of exploratory analyses needed to be carried out to reduce the numbers of items included in the final factor analyses, which is less than ideal for locating symptom factors. The low STI ratio also meant that gender-stratified factor analyses could not be carried out.

The development of the ACA as an adolescent-specific version of the ACC provides opportunities to consider

Conclusion

The Assessment Checklist for Adolescents — ACA is a 105-item carer-report psychiatric rating scale designed for population and clinical research with 12 to 17 year-olds in care, and for use as a clinical assessment tool. While its content is largely derived from the Assessment Checklist for Children, the ACA's factor structure differs somewhat from that of the ACC. These differences likely reflect the introduction of items that measure additional clinical phenomena, as well as substantive

Acknowledgements

The Treatment Foster Care Program for the Children's Aid Societies of Durham, Highland Shores and Kawartha-Haliburton, in Ontario, Canada, kindly contributed ACC scores for the present analyses. The CICS was funded and approved by the NSW Department of Family and Community Services.

References (13)

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