An Instrument for Dimensional Diagnosis of a Child Constitution (ICC) Individualizing the Care for Children with Developmental Disorders- Juniper Publishers
Juniper Publishers- Journal of complementary medicine
Abstract
Objectives: Developmental disorders present
themselves with complex problems that may threaten the child’s
development. In every child a disorder shows itself in a unique way,
which makes it necessary to individualize. The objective of this study
is to develop an instrument that provides a dimensional diagnosis by
mapping the degree of (dis) balance on three domains of child
development. The instrument is based on an anthroposophic anthropology
and typology. Materials and methods: The typology of the child’s
constitution is operationalized using concept mapping en consensus
building with experts. In a pilot study the psychometric properties of
the instrument were preliminary tested on children with developmental
disorders in Dutch institutions.
Results: The Instrument for diagnosis of a
Child Constitution (ICC) consists of two parts. Part I contains 36 polar
items in three subscales of 12 items, and is completed by healthcare
professionals. Part II consists of three Visual analogue scales
(VAS-scales and is completed by a practitioner. The outcome (the scores
of Part I and II) is a profile of the child’s constitution, showing the
(dis)balance on three domains of child development. A pilot study with
38 children demonstrates positive face validity, and moderate internal
consistency and inter-rater reliability of the ICC.
Conclusion: The ICC has been developed as a
diagnostic instrument to assess individualized dimensional diagnosis of
children with a developmental disorder. Future studies will focus on
validation of the instrument.
Keywords:Dimensional Diagnosis; Child Constitution; Developmental Disorders; Anthroposophic anthropology; Typology; ICC; Tacit knowledgeAbbrevations: ASD: Autism Spectrum Disorder; ADHD: Attention Deficit Hyperactivity Disorder; COSMIN: Consensus-based Standards for selection of health Measurement Instruments; McDD: Multicomplex Developmental Disorder
Introduction
Developmental disorders
Developmental disorders include a broad range of
psychological and physical symptoms through which children differ from
what is generally considered as normal. These neurodevelopmental
disorders [1] have a pervasive effect on the child’s development; they
may affect it permanently in multiple developmental domains. The
following disorders are mostly included: language/speech, learning and
motoric disorders, Autism Spectrum Disorder (ASD), Attention Deficit
Hyperactivity Disorder (ADHD), Obsessive Compulsive Disorder, Conduct
Disorder and tic disorders. Also, intellectual disabilities and genetic
syndromes, like Down’s syndrome. There are clinicians who also consider
early traumatic experiences that affect the
development of the child’s capacity to build attachments with others as a
developmental disorder [2].
The prevalence of developmental disorders seems to be
increasing. In American research amongst children between the ages of 3
and 17, Boyle et al. [3] found an increase in the prevalence from
12.84% to 15.04% between the periods 1997/1999 to 2006/2008. In this
study ADHD, ASD, learning disorders, sensory disorders, intellectual
disabilities, epilepsy and motoric disorders were included. The
prevalence of ASD increased from 0.19% to 0.74% in the aforementioned
period, ADHD from 5.69% to 7.57% [3].
Developmental disorders rarely occur in isolation.
Often there is comorbidity, such learning disorders and ASD [4]. More
than 70% of the children with ASD have at least one comorbid
disorder [5] and 40% have two or more [6].
Kaplan [7] considers the term ‘comorbidity’ of limited
value in relation to developmental disorders; they are atypical
and neurological dysfunctions that lead to a continuum of
disorders. In each child a developmental disorder has an unique
presentation. In the DSM-5 [8], the categorical structure does
not always fit the realities of clinical practice and scientific
research. Therefore, steps in a more dimensional approach and
individualization in diagnosis is to be preferred.
Diagnostics
Theories relating to developmental disorders are
multidisciplinary, with contributions from the field of
developmental psychology [9] and medicine [10]. This links
well with an interdisciplinary approach in the examination and
diagnosing of children with a possible developmental disorder
[11]. This way of diagnosing consists of the classification of the
disorder and mapping out the child’s individual functioning.
Classifying disorders in well-defined categories has led to
the development of protocol and evidence-based treatments
for similar problems [12]. A disadvantage of the categorical
classification is the often all-or-nothing threshold concerning
the number of criteria that must be adhered to in order to
establish the presence of a disorder [13]. Developmental
disorders manifest themselves in varying degrees in different
developmental domains [14]. The alignment with the individual’s
situation is achieved more effectively in a dimensional approach
[15,16].
Constitutional diagnostics
In the anthroposophical inspired care for children with a
developmental disorder determining the constitution is a method
to map out the child’s individual situation [17]. This method
in health care has derived from a typology of the constitution,
which has its basis in the anthroposophic anthropology [18-20].
The concept of ‘type’ used here can be characterized as a
dynamic and plastic complex of ways to constitute similar but
not identical living organisms [21]. The type functions as the
active designer, which expresses itself in form and function of
an organism and organs. For living nature the type is what laws
of nature, like gravity, are for the dead nature. As such, the type
is invisible to the physical senses. It does apply to the individual
organisms that are manifestations of a type. Every living
organ(ism) is an unique manifestation of a type. In the typology
of the constitution three organs as domains of development in
the child’s functioning are distinguished, a cognitive, an affective
and a conative domain. In these domains the typology focuses
on a designer, a type. This type constitutes in each domain biopsychosocial
processes of
development, with on both extremes of a continuum a polar
pair of one-sidedness. In the constitutional diagnostics of a child
the degree of (im-)balance on the continuum in these domains is
identified [19].
On the continuum in the domain of cognitive functioning the
quality of perception and thinking are central. On the one hand,
this consists of the capacity to bring form and congruency in
perceptions, as well as in thoughts and memories. On the other
hand, it consists of the capacity to let go of these thoughts and
to forget them. The domain of affective functioning is concerned
with the experience and expression of feelings and emotions and
the ability to pull back and close oneself off from the environment.
The domain of conative functioning is centered on movement and
mobility. The capacity to slow down and be passive and on the
other hand to move and be active.
The child’s functioning can be registered on a continuum
for each of these domains, with sidedness on either sides of a
healthy middle area. In the three developmental domains, the six
constitutional images represent that sidedness. The names that
characterise the six images consist of a verb and a noun:
a) Densifying/Obsessive versus Dissolving/Forgetful for
the cognitive developmental domain
b) Closing/Clenched versus Opening/Outflowing for the
affective developmental domain
c) Decelerating/Heavy versus Accelerating/Light for the
conative developmental domain
Each child has its own degree of (im-)balance in the
continuums of the three developmental domains, which defines
its constitution.
Theoretical framework
The child’s development occurs as a transactional process
[9] in a continuous exchange between the organism and the
environment; both of which are continuously changing [22,23].
A developmental disorder intervenes in this interaction. For
adaptation and recovering of balance in functioning, the child’s
organism uses self-regulating capacities, such as resilience [24].
Recognising these capacities is linked to attitudes regarding
health as a dynamic phenomenon, as the capacity to adapt and
maintain autonomy in light of physical, emotional and social
challenges [25]. The typology of the constitution is built on
this concept of health. The three developmental domains that
are used in this typology - the cognitive, affective and conative
domains - are known from psychology [26,27] and psychiatric
research [28,29].
The term ‘constitution typology’ refers to the basis of
constitutional characteristics. In the literature, the term
‘constitution’ is used as a reference to predisposition, the genetic
constitution of the child. The genetic constitution is responsible
for the development of structure and functions of an organism
[30]. In this meaning, constitution is usually an immutable, static
fact of the child’s predisposition. However, in the constitution
typology, the constitution is a dynamic phenomena. The child’s
constitution changes during lifetime under the influence of the
environment and the child’s own personality. As a result, this
meaning of constitution is influencable through treatment.
As an indicator of the coherence between predisposition
and bio-psychosocial phenomena the term constitution seems to
be losing its meaning, in favour of the term ‘temperament’. This
appears from the description of temperament as predispositionbased
individual differences in behaviour [31]. Temperament
consists of personality characteristics that have a genetic and
neurobiological foundation [32]. There are similarities and
differences between the meaning and role of ‘constitution’
and ‘temperament’ in the literature. A similarity is that in
the constitutional images, constitution refers to coherence in
predisposition and bio-psychosocial processes; comparable
to temperament [18,19,33]. A difference is the relation to
developmental disorders. Temperament is considered to be a
personality factor that protects the child, or constitutes a risk
factor for the development of disorders [34]. The used meaning
of constitution here consists of the actual bio-psychosocial
functioning of the child, including a possible developmental
disorder.
Aim and research questions
The aim of this study is developing a measuring instrument to
determine the degree of (im-)balance in the child’s constitution.
This study supports the scientific basis of Integrative Healthcare
[35] and in particular, anthroposophical inspired healthcare
[36]. The study is societally relevant because it contributes
to the further development of an anthroposophic healthcare
that is focused on the situation of the individual child and its
environment. Previous steps in the scientific justification are a
methodical description of the healthcare [17] and the typology
of the constitution [19,20,37].
The questions of this study are:
a) Which bio-psychosocial phenomena should be included
in the instrument?
b) Which design of the instrument fits best the
constitutional typology?
c) What are the outcomes of the investigation into internal
consistancy, inter- and intra-rater
d) reliability?
Methods
To answer the first question, concept mapping has been used
in a group of experienced professionals. We used consensus
building to determine which items should be included and how
the instrument should be designed. For the third question, a pilot
study was conducted with the cooperation of practitioners. A
questionnaire was filled out to determine instrumental usability.
Concept mapping
Concept mapping is used for the operationalisation of
concepts in (healthcare-based) research [38]. It entails the
generation, prioritisation and clustering of phenomena, which,
through a cluster analysis, leads to an overview of the attitudes
of the group of people in question [39]. In this study, we worked
with the written variant of concept mapping [40] in order to
generate, prioritise and cluster the concerning characterising
bio-psychosocial phenomena for the first research question. For
this analysis we used the Ariadne programme1, which combines
statistical techniques, Principal Components Analysis and
Hierarchical cluster analysis.
Experienced professionals: Experienced professionals can
be considered the carriers of ‘tacit knowledge’ [41]. A total of 42
people were asked to participate in this study (12 professional
supervisors, six artistic therapists, 11 remedial educationalists/
psychologists and 13 doctors). Of these 42, 14 people opted out
of the study (ill, no time) and six people did not response. The
remaining group of 22 experienced professionals consists of
three professional supervisors, four therapists, eight remedial
educationalist/psychologists and seven doctors. Their average
number of years of experience in healthcare was 16.2 years
(range: 6.4 - 21.3).
Two rounds of questionnaires: The 22 participants received
a questionnaire in two rounds. All of the participants (100%)
responded to the first questionnaire; the second questionnaire
had a response rate of 63.6% (14 participants). In the first round
the participants were asked which bio-psychosocial phenomena
they consider typical for each constitutional domain on the
basis of their expertise. In the second round, the participants
were asked to prioritise the gathered phenomena from the first
round. In addition, they were asked to categorise the connected
phenomena in clusters. Prioritisation could be given on a fivepoint
scale, ranging from low (1) to high (5)2. The phenomena
with an average prioritisation higher than 3.5 were considered
important for the diagnostics of the constitution.
Consensus building
Consensus is the agreement regarding a matter by experts,
in light of the actual situation of the empirical study and their
shared professional experience, and in words that mean the
same to the discussion partners [42].
In three meetings with the experienced professionals
and researchers, consensus building took place between
the professionals and researchers to answer the second and
third question, relating to the composition and design of the
instrument.
Design of the instrument
In the consensus group, the researchers put forward
a proposition for the construction of the instrument. In
this proposal, the principle of polarity was applied and the
constitution was made measurable in two ways. We chose to use measuring scales, through which the degree of (im-) balance in a
system could be scored.
The first way of measuring the constitution consists of
judging polar-formulated phenomena on a seven-point Likert
scale, with a range from -3 to +3. With this, it is indicated
whether there is a balance, and if so/or not, to what extent there
is or is not a balance disruption in each of the polar-formulated
items. The score 0 points towards a balance; all other scores
indicate a greater or lesser deviation from this balance. This way
of measuring has an analytical character; the child’s scores are
determined on the basis of separate phenomena.
The second way of measuring consists of the clinical
evaluation by the practitioner, regarding the degree of balance, or
one-sidedness, in each of the three pairs of the polar phenomena.
By comparing the image of the child as it appeared in the
diagnostic investigation with a characterising description of the
three pairs of polar phenomena, an experienced professional
can determine how the image that she/he developed of the child
relates to this. In the instrument he can indicate this assessment
on three Visual Analogue Scales (VAS scales). The measuring of
VAS scales appeals to the practitioner’s tacit knowledge [41]
and the capacity to recognise a pattern or ‘Gestalt’ [43] and is
connected to the method of ‘pattern recognition’ [17,44].
Pilot study
To answer the third question, through a pilot study with
38 children, the instrument was investigated in terms of
internal consistency, inter-rater reliability and instrumental
usefulness. Fifteen practitioners, six doctors and nine remedial
educationalists/psychologists cooperated in this pilot study.
For each of the 38 children, the instrument was filled out;
the polar-formulated items separately by two professional
supervisors and the VAS scale separately by two practitioners, a
remedial educationalists/psychologist and a doctor. The child’s
practitioner filled out the requested personal information:
initials, date of birth and gender, the actual DSM classification
and determined level of functioning through an intelligence
investigation of the child, the date of entry and the practitioner’s
own name and job position.
The internal consistency of the instrument of the three
subscales was determined by establishing Cronbach’s alpha.
The inter-rater reliability was determined by calculating the
Pearson correlations of unweighted sum scores, between pairs
of evaluators for each of the three subscales in Part I and the
three VAS scales in Part II. The Consensus-based Standards for
selection of health Measurement Instruments (COSMIN) [45],
gave as a criterion for the quality of the internal consistency a
Cronbach’s alpha of >.70 and a Pearson correlation of >.70 for
the inter-rated reliability. The instrumental usefulness was
investigated with an inventory of the experience of respondents
using the instrument, and through the determination of the
missing values, whereby a maximum percentage of 5% was
established [46].
Results
Concept mapping
Creation the inventory and prioritization: The number
of phenomena, which were generated by the experience experts
in the first questionnaire and received an average prioritisation
equal to or greater than 3.5 on the five-point scale in the second
round, were the following for the polar phenomena:
a) Densifying/Obsessive - Dissolving/Forgetful: in the
first round: 38 and 36; and in the second round: (46.6% of
the number generated in the first round) and 17 (47.2%);
b) Closing/Clenched - Opening/Outflowing: 60 and 59
in the first round; in the second round: 34 (56.6%) and 26
(44.1%);
c) Decelerating/Heavy - Accelerating/Light: 40 and 60
in the first round; in the second round: 17 (42.5%) and 29
(48.3%).
Clustering: The phenomena, which were clustered and
prioritised by the separate participants, were processed into
an average clustering in the Ariadne programme, using the
Principal Components Analysis and Hierarchical cluster analysis.
The choice for two clusters presented the best options for
interpretation, and with that, an organising principle for the
selection of the items to be included in the instrument. The
first cluster contains psychological phenomena and the second
cluster consists of biological/physiological phenomena in their
related developmental domains.
Consensus building
In the consensus discussions with the experience experts, an
agreement was reached regarding the researchers’ proposition
relating to the construction and design of the instrument,
as described in the section Methods. The Instrument for the
determination of the Child’s Constitution (ICC) consists of
two parts. Part I contains 36 polar-formulated items, for the
assessment on a seven-point Likert scale. Part II contains
three VAS scales, which indicate the degree of balance or
imbalance in the developmental domains. For Part I of the
ICC, the number of items for each of the three developmental
domains is maximised at 12. Items have been selected from
the two clusters of phenomena, with a minimum of two items
per cluster. The selection of the items took place on the basis
of the ranking according to the prioritisation. For Densifying/
Obsessive versus Dissolving/Forgetful, ten items from the first
cluster were selected, and two items from the second cluster. For
both the Closing/Clenched versus Opening/Outflowing and the
Decelerating/Heavy versus Accelerating/Light polarities, nine
items were selected from the first cluster and three items from
the second cluster.
In the explanation with the ICC it is indicated that
for the
filling out of the child’s functioning, the month prior to the
moment of entry should be considered leading. Part I of the
ICC is filled out by people who are professionally involved in the care
of the child. Part II is filled out by the diagnostically
responsible practitioner. For the filling out of Part II of the ICC, a
characterising description of the three constitutional types have
been formulated in clarifying notes, as a support for the filling
out of the VAS scales.
Pilot study
Composition study group: The ICC was used for the
diagnostics of 38 children/adolescents; 10 girls and 28 boys.
Their average age was 10.0 years (range: 7 - 16). Of these
children, 14 were classified as having a disorder in the Autistic
Spectrum, six had Multicomplex Developmental Disorder
(McDD), five ADHD, three an Attachment disorder and one child
had Down’s syndrome. The nine other children were diagnosed
with an intellectual disability.
The children’s level of functioning varied from averagely
gifted (five children) to severely mentally disabled (one child);
17 children functioned at a moderately mentally retarded level,
11 children had a slight mental disability and four children had
a moderate mental disability. Of the children and adolescents,
seven were in day-care treatment; the remaining 31 were
receiving clinical treatment.
Internal consistency: Cronbach’s alpha for Part I in its
entirety is .79. For the three subscales of Part I, Cronbach’s alpha
is .64 (Closing/Clenched-Opening/Outflowing); .67 (Densifying/
Obsessive-Dissolving/Forgetful); and .76 (Decelerating/Heavy-
Accelerating/Light).
Inter-rater reliability
The Pearson correlations for the subscales of Part I was
significant: **p<.01:
a) Densifying/Obsessive - Dissolving/Forgetful .66**
b) Closing/Clenched - Opening/Outflowing .69**
c) Decelerating/Heavy - Accelerating/Light .82**
The Pearson correlations for the three VAS scales of Part II:
a) Densifying/Obsessive - Dissolving/Forgetful .44**
b) Closing/Clenched - Opening/Outflowing .25
c) Decelerating/Heavy - Accelerating/Light .47
Instrumental usefulness: The number of missing values in the
76 filled-out instruments was 45. In Part I of the instrument, 42
missing values were counted, spread over 19 of the 36 items. In
Part II, the VAS scales, there were 3 missing values. In total, there
were 45 missing values for 76 (number of filled out instruments:
38 children x 2) x 39 (number of items: 36 in Part I + 3 in Part II)
= 2.964 items; a percentage of 1.51%.
The practitioners and supervisors indicated that the
seven-point Likert scale in Part I provided sufficient room for
nuancing in the answering of the questions. A few questions
could not be responded to by all supervisors on the basis of
their personal experience. This applied to questions regarding
physical functioning, which were intended for the supervisors
working in the day care treatment and artistic therapists. None
of the practitioners added any remarks in the characterising
description of the types in the Clarification of Part II of the
instrument.
The following modifications were made to the instrument
following the findings relating to the instrumental usefulness:
four body-oriented items in Part I of the instrument, which had
not been filled out by all supervisors, were made optional.
Discussion
This study concerns the development of the Instrument
for the determination of the Child’s Constitution (ICC) for the
dimensional diagnostics of children with a developmental
disorder. The selection of items for the instrument was
established through concept mapping and consensus building
with 22 experience experts with an average of 16.2 years of
working experience in healthcare. This has resulted in an
instrument that consists of three developmental domains and
two sections. Part I contains 12 polar-formulated items for each
of the three domains and is filled out by professional supervisors.
Part II has a VAS scale for each of the three domains and
displays the clinical evaluation of the practitioner responsible
for the child’s diagnosis. In a pilot study with 38 children/
adolescents, the internal consistency, the inter-rater reliability
and instrumental usefulness were exploratively investigated.
Cronbach’s alpha is good for the entire instrument (.79) and
‘mediocre’ to ‘good’ for the three subscales of Part I (.64 - . 76).
The Pearson correlation for the inter-rated reliability of the
three subscales of Part I ranges between .66 and .82; all three
are significant (p<.01). For the three VAS scales in Part II, the
correlations are low; in the .25 to .47 range. Except the subscale
Closing/Clenched - Opening/Outflowing, these are statistically
significant (p<.01). Investigation into the instrumental usability
has led to modification of the instrument: four items in Part I
of the instrument were made optional. These are body-oriented
biological/physiological items, which cannot be filled out by
all supervisors, as shown by the number of missing values per
item. The number of missing values remains far below the set
maximum of 5% with a percentage of 1.51%. All 36 items of
Section I are maintained.
A first limitation of the study is that the constitutional
approach is founded on the anthroposophic anthropology,
of which the philosophical and empirical justification of the
theoretical framework are still developing [39]. A second
limitation concerns the quality of the pilot study into the validity
and reliability of the developed instrument. The study group
is small and not randomly composed, nor have all aspects of
validity and reliability been tested.
Conclusion
Nonetheless, the ICC in this phase of its development is
already of importance to anthroposophic daily practice. It
provides handles for the individualisation of the diagnostics and
for individual choices in child-oriented treatments. Additionally,
it contributes to the explication and operationalisation of
anthroposophic concepts, and by doing so, to further scientific
support base of anthroposophic-inspired healthcare. Generally
speaking, the construction of the ICC with the polar-formulated
items is an example of a questionnaire which is based on a
dynamic healthcare concept.
Subsequent steps that will be taken in the developmental
process of the instrument are:
improvement of the manual of the use of the instrument,
research into the reliability, validity and respon
siveness of
the instrument, and further theoretical justification of the
constitutional approach towards healthcare.
Comments
Post a Comment