Recent studies suggested that rates of psychopathology may be as prevalent in preschoolers as in school-age children . Because of that, it is necessary to have a diagnostic instrument that is specifically made for infants and preschoolers like diagnostic infant preschool assessment (DIPA).
Because of the need for an instrument like DIPA in the clinical applications and research in Egypt and the Arabic country, the aim of this study was to translate and evaluate reliability and validity of diagnostic infant preschool assessment (DIPA) on an Egyptian sample.
This would be the first Egyptian study to translate and cross culturally adapt the DIPA, keeping accordance with international guidelines to ensure the quality of results. The final version of the translated and adapted DIPA into Arabic showed high levels of acceptance and verbal understanding.
Translation is not a single process leading from a starting point ST = source text to a target point TT = target text, but a more complicated and recursive process that comprises an infinite number of feedback loops, in which it is possible to return to earlier stages of the analysis . The successful accomplishments of instrument translation primarily determined by the professional knowledge, cultural experience, and linguistic competence of the translators as well as their acquaintances of the study objectives. They also must be aware of the aim of the tool so that the meanings of terms are in agreement with the context [17, 18]. In our study, both translators and back translators matched these criteria, but the back translator was fully blind about the original version of DIPA to avoid any bias in the correction of the translation.
The current study used an expert panel discussion in the process of translation of the DIPA. This helped to improve the quality of translation by the experts’ constructive feedback and discussion about usage of culturally, psychologically, and religiously sensitive translated words.
After developing the final version, we measured the test-retest reliability and validity of the Arabic instrument on a sample of 30 children.
In terms of test-retest reliability, categorical tests were conducted between the results of the two settings for each disorder on two types of outcomes: diagnosed and subclinical cases.
Our findings show satisfactory results for test-retest reliability, as kappa was almost perfect agreement (kappa > 0.81) for all disorders with significant P value. This result is slightly higher than the results of the DIPA 2010 version. The kappa was substantial (kappa 0.6–0.8) for one disorder (MDD), fair to good (kappa 0.4–0.6) for four disorders (ADHD-inattentive, ADHD hyperactive, PTSD-AA, and SAD), and poor (kappa 0–0.4) for one (ODD). This may be because of that, this version of DIPA 2017 with Likert-style answers on a 0-4 scale instead of yes/no answers in the DIPA2010 version and this allows a greater range of sensitivity.
This finding is comparable with several other studies, which used other tools like affective disorders and schizophrenia for school-age children (K-SADS-PL) for the assessment of preschool children, which is one of the most used instruments in child psychiatry. The kappas for all KSADS-PL positive screening symptoms were between 0.70 and 0.86 (all P values < 0.01) . And test-retest reliability of the preschool age psychiatric assessment (PAPA) kappas ranging from 0.36 to 0.79 , and in the Child and Adolescent Psychiatric Assessment (CAPA) overall reliability of diagnosis ranged from K = 0.55 (conduct disorder) to 1.0 (substance abuse or dependence) . Test-retest agreement of the diagnostic interview for children and adolescents for parents of preschool and young children (DICA-PPYC) with a mean interval of 8.8 days ranged from slight to excellent (kappa from 0.39 to 1) for DSM-IV-TR and from fair to good (kappa from 0.49 to 0. 77) for research diagnostic criteria-preschool age diagnoses .
One of these study limitations is that our sample did not involve children under 1.5 years. Further Egyptian studies are required to be conducted on children below this age to detect the lower age limit for which a diagnostic instrument is valid.
The Arabic version of DIPA 2017 revealed acceptable criterion validity when compared to the CBCL. For categorical variables, kappas were substantial (kappa 0.61-0.80) for one disorder (CD), moderate (kappa 0.41-0.60) for five disorders (PTSD, GAD, MDD, ODD, Sleep), poor (kappa 0-0.4) for three disorders (SAD, RAD, and ADHD). In addition, the P value was significant for all disorders except SAD and RAD.
These findings were comparable with the DIPA 2010 version’s validation, kappas for disorders with impairment were fair to good for one disorder (SAD) for clinicians, and for three disorders (ADHD-hyperactive, ODD, and PTSDAA) for RAs. Kappas were poor for five disorders (ADHD-inattentive, MDD, PTSD-DSMIV, GAD, and OCD) for both clinicians and RAs, and for two more disorders (ADHD hyperactive and PTSD-AA) for clinicians, and for one more (SAD) for RAs .
In addition, the validity of the Arabic DIPA 2017 was slightly higher than the DIPA 2010 . In the validation study of the DIPA 2010 version, there were no cases of GAD and they did not measure the DIPA validity for the following disorders: conduct disorders (CD), reactive attachment disorders (RAD), and sleep disorders. Contrary to our study as we had cases of GAD, CD, RAD, and sleep disorders. However, there were no bipolar or OCD cases in both studies. The lack of these disorders is consistent with the fact that they are rare disorders in this age group .
Another study limitation is that the size and character of the sample limited the ability to examine some psychiatric disorders like bipolar disorder and OCD, and to some extent RAD. In our study internalizing disorders were generally less prevalent and there were too few symptoms of these disorders to make reliable conclusions. And previous studies to investigate less prevalent psychiatric disorders (like OCD, BAD) concluded that samples need to be recruited from a specialty clinic, so they could find enough symptomatic patients .
Despite this limitation, our study is considered the first trial for translation and validation of DIPA instrument. In addition, its sample size is still relatively larger than previous studies for some other instruments developed for older children, including the diagnostic interview for children and adolescents (n = 27) , and the schedule for affective disorders and schizophrenia for school-aged children (n = 20) .