Cognition, Brain, Behavior. An Interdisciplinary Journal Copyright 2011 Romanian Association for Cognitive Science. All rights reserved.

. ISSN: 1224-8398 Volume XV, No. 1 (March), 95-110

THE STANDARDIZATION OF EARLY CHILDHOOD INVENTORY-4 (ECI-4) ON ROMANIAN POPULATION - A PRELIMINARY REPORT
Anca BLAJ*1, Monica ALBU1, Mihaela PORUMB1, Mircea MICLEA1, 2
2

Cognitrom LTD, Cluj-Napoca, Romania Department of Psychology, Babe-Bolyai University, Cluj-Napoca, Romania

ABSTRACT
This study reports the standardization of the Early Childhood Inventory (ECI-4) on Romanian population. Psychometric properties were measured both in clinical and non-clinical groups of children aged between 3 and 7 years. The results of the statistical analysis emerged revealed that ECI-4 is a reliable and valid screening tool for Romanian childrens mental health, being in consonance with the original version of ECI-4. The study also presents the elaboration of norms procedure. ECI4 is a useful screening tool for psychiatric problems in preschool children. It can be used in assessment, intervention, follow-up of the treatment, as well as for research purposes.

KEYWORDS: preschool mental health, screening instrument, behavior problems,

multi-informant evaluation.

INTRODUCTION It is being estimated that 20% of children could benefit from mental health services (Mash & Dozois, 2003 cited in Hartung & Lefler, 2010); however, approximately 80% of these children do not receive such aid in the USA ( Kataoka, Zhang, & Wells, 2002 cited in Hartung & Lefler, 2010). Patients would be more likely to benefit of mental health services if such services were suggested by professionals like school psychologist or pediatrician, after a screening process. Childrens mental health screening is not being yet a widely used assessment method. In Romania, especially, there is a complete lack of screening tools used for mental health problems. Many children are deprived of early intervention because most of
*

Corresponding author: E-mail: balajanca@gmail.com

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these problems remain undiagnosed, and sometimes, they are of interest only when children are unable to adapt to school requirements and teachers complain about their behavior. Mental health screening tools for kindergarden children can be valuable for early detection and treatment of mental health problems. The Early Childhood Inventory-4 (ECI-4; Gadow & Sprafkin, 2000) is a screening tool for symptoms of behavioral, emotional and cognitive deficiencies of over a dozen of psychiatric disorders specific to childhood. Items in the ECI-4 are based on diagnostic criteria specified in the American Psychiatric Associations (1994) Diagnostic and Statistical Manual of Mental Disorders (DSM). ECI-4 facilitates the gathering of information in clinical and educational settings from parents and teachers about the symptoms of early childhood emotional, behavioral and cognitive disorders (Gadow & Sprafkin, 2000). ECI-4 is a useful tool because compared to a clinical interview it offers an alternative to structured psychiatric interviews which are time consuming, too long for standard clinical applications (Gadow & Sprafkin, 1997). The diagnostic categories included in ECI-4 were selected based on the highest prevalence rates among other diagnostic categories in child mental health. In general, there were included disorders that are more common and prevalent in child psychiatric populations and special education programs. In the case of a child attending a preschool facility, it is highly important to gather information from both teacher and parents. Several instruments for young children have different versions for teachers and parents (Gresham & Elliott, 1990; Kotler & McMahon, 2002, cited in Gadow & Sprafkin, 2000). The rationale is that: parents and teachers differ in their ability to correctly identify certain disorders because of the different demands placed on the child in the diverse settings, like home and kindergarden; also, it is believed that parents and teachers have access to different perspectives on childrens behavior (Achenbach, Dumenci, & Rescorla, 2003 cited in Gadow & Sprafkin, 2000), both critical in drawing accurate conclusions; teachers have the opportunity of observing the children in classrooms and are able to identify a wide range of behavioral, emotional, and learning-related problems in the context of comparisons between children, while parents observe their children in daily interactions in the household (Huffman & Nichols, 2004); some children are more apt to reveal their inner state or to express a behavior to one caregiver than another; the identification of the settings in which the child experiences greater difficulty has important diagnostic and treatment implications. Obtaining information from more than one source increases the probability of generating a more accurate picture of a particular childs difficulties. Taking into consideration all the reasons listed above, a multirater perspective is highly important when evaluating a child. Consequently, ECI-4 has both a parent and a teacher forms. The ECI-4 Parent Checklist assesses the symptoms of the most common childhood emotional and behavioral disorders (see Table 1). In addition, the ECI-4
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addresses problems in daily habits (i.e., eating, sleeping, toilet training) to ensure a comprehensive evaluation. Table 1 presents the mental health problems evaluated by ECI-4, through both Parent and Teacher Checklists.
Table 1. Mental health problems evaluated by ECI-4 Parent and Teacher Checklist Parent Checklist A ADHD Innatentive Type A ADHD Hyperactive-impulsive A ADHD combined B Oppozitional Defiant Disorder C Conduct Disorder PCS Peer Conflict Scale D Separation anxiety E-57 Specific phobia E-58 Obsessions E-59 Compulsions E-60 Motor tics E-61 Vocal tics E-62-64 Generalized anxiety E-65 Selective mutism F Major depressive disorder F Dysthymic disorder F Dysthymic disorder (research criteria) F77 Adjustment disorder G Social phobia H Sleep disorders I. Elimination problems J Posttraumatic stress disorder K Feeding problems L Reactive attachment disorder M Autistic disorder M Asperger syndrome Teacher Checklist A ADHD Innatentive Type A ADHD Hyperactive-impulsive A ADHD combined B Oppozitional Defiant Disorder C Conduct Disorder PCS Peer Conflict Scale E-57 Specific phobia E-58 Obsessions E-59 Compulsions E-60 Motor tics E-61 Vocal tics E-62-64 Generalized anxiety E-65 Selective mutism F Major depressive disorder F Dysthymic disorder F Dysthymic disorder (research criteria) F77 Adjustment disorder G Social phobia I. Elimination problems J Posttraumatic stress disorder M Autistic disorder M Asperger syndrome

The Teacher Checklist differs from the Parent Checklist in three ways. First, the Teacher Checklist obtains information about educational setting and special education services. Second, the Teacher Checklist excludes items included in the Parent Checklist about which the teacher is unlikely to have accurate information (e.g., sleep problems, eating problems). Third, the Teacher Checklist does not include a comprehensive listing of all the symptoms that appear in the Parent Checklist for disorders that are characterized by behaviours that are problematic in the home setting (e.g., separation anxiety). Although these deletions from the Teacher Checklist obviously resulted in fewer items being included, the numerals assigned to each symptom are the same for both versions of the ECI-4. In
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other words, in order to facilitate comparisons between parent and teacher reports, the Teacher Checklist was not renumbered even though certain symptoms were deleted. In conclusion, Parent Checklist has 108 items and the teacher Checklist has only 87 items plus 8 items that evaluate the level of child development. Individual items can be scored in two different ways: the Screening Cutoff score method and the Symptom Severity score method. The Screening Cutoff score method determines whether or not the symptom occurs often enough to warrant concern. The total number of symptoms rated as being of concern for a specific disorder is then compared with the Symptom Criterion score (i.e., the minimum number of symptoms necessary for the diagnosis of a specific disorder) to determine if the child should be evaluated in greater detail in order to be able to render a diagnosis. Respondents are required to indicate the frequency (i.e., never, sometimes, often or very often) with which the child engages in behaviors relevant for the problems being assessed (symptomatic behaviors). A specific behavior is generally not considered to be important if it is rated as occuring never or sometimes. If a respondent rates a behavior as occurring often or very often, the symptom is considered to be a clinical problem. The DSM specifies the number of symptoms that must be present to warrant a diagnosis (Symptom Criterion score), which is the basis for determining the Screening Cutoff score. For example, in DSM-IV, a diagnosis for oppositional defiant disorder requires that at least four out of eight symptoms be present (i.e., Symptom Criterion score=4). If a childs Symptom Count score (number of symptoms endorsed as being of clinical concen) is equal to or greater than the Symptom Criterion score, then his/her Screening Cutoff score is yes. If this score is lower than Symptom Criterion score, as in this exemple 4, than the screening Cutoff score is no. The Symptom Severity score is simply a sum of the item scores, which range from 0 to 3 (i.e., never=0, sometimes=1, often=2, and very often=3). Items scores are summed to generate a Symptom Severity scores for each category. Based on the norm samples, this score classifies the severity of child symptoms as low, moderate and high. The present study aims to adapt, validate and create norms for the Romanian version of ECI-4 and to determine the use of this screening tool for identifying psychiatric problems in children aged between 3-7 years. METHOD Participants A large sample of participants was considered, consisting of both clinical (N=57) and non-clinical populations (N=489). In the clinical sample, all the children had a psychiatric diagnostic already established by a mental health specialist (i.e., psychiatrist, clinician). The psychiatric diagnostics included in the clinical sample
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were: AD/HD inattentive type, AD/HD hyperactive-impulsive type, AD/HD combined type, Oppositional defiant disorder, Generalized anxiety disorders, Elimination problems, Posttraumatic stress disorder, Autistic disorder and Asperger syndrome. The total number of children included in this study were N=546. All this participants were evaluated by two kinds of informants: kindergarden teachers and parents. Data were collected in kindergarden, mental health hospitals, medical clinics or at participants home. The scales were administered individually or in group, depending on the situation. All informants gave their informed consent before completing the scales. The sample characteristics for each group: number of children, sex, mean age, standard deviation and age range of participants are described in Tabel 2. The sample was recruited taking into consideration the geographical areas in Romania, as well as representative urban (57.2%) and rural (42.8%) population distribution according to the latest census data showing that the urban preschool population represents 56.3% of the total preschool population. For validity and test-retest reliability studies the samples were different. The samples of participants used for each study are described in the designated section.
Table 2. Distribution of participants according to age, sex and the sample Non-clinical sample Boys Girls Total 245 244 489 2-7 3-7 2-7 4.69 4.62 4.65 1.21 1.24 1.22 Boys 36 2-7 5.00 1.57 Clinical sample Girls Total 21 57 2-7 2-7 4.43 4.79 1.47 1.54

Total Age min.-max. (years) Mean age (years) SD

Procedure The study consisted of four phases: (1) items forward and back-translation; (2) a pilot study for verification of translated items; (3) determination of validity and reliability and (4) the creation of norms on Romanian population. The first two phases are described in the next paragraph. The first phase of forward and backward translation was completed in two weeks. The forward translator was a fluent speaker of English, but her mother tongue was Romanian. The translation aimed was at the conceptual equivalent of a word or phrase, not a word-for-word translation (not a literal translation). Technical and highly scientific terms and expressions were avoided. The translated form was subject for discussions, questioning and suggesting alternatives for certain words or expressions. The expert panel included the original translator and three specialists in psychology. They agreed on an initial version of ECI-4 in the Romanian
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language. This completely translated version of ECI-4 was then given to another independent translator who had no knowledge of the original checklist for backtranslation. As in the initial translation, emphasis in the back-translation was on conceptual and cultural equivalence. A preliminary version was obtained after additional discussions with the panel experts. In the second phase, a pilot study was initiated. The preliminary version of ECI-4 was administered to 34 parents and kindergarden teachers, in order to test the instructions, item comprehension, and the ease of administration. Few changes were made in relation to this version, like adopting a simpler, succinct formulation of the instructions in order to improve their clarity, and using alternatives for some words to better conform to the spoken language. After summarizing and analyzing all the problems found during the pre-testing and the modifications proposed, the final version of ECI-4 was elaborated. Once the final version of the scale was ready for use, validity and reliability studies were initiated with a reasonable sample of participants. Following these studies, we proceeded to create the norms on Romanian population. Measures The Early Childhood Inventory-4 (ECI-4, Gadow & Sprafkin, 2000) was described in the beginning part of this study. Spence Preschool Anxiety Scale (Spence, 1998) is a caregiver report instrument composed of 28 items assessing problems related to five types of anxiety disorders in children aged between 3 to 7 years: Generalized Anxiety Disorder, Social Anxiety, Obsessive Compulsive Disorder, Physical Injury Fears, and Separation Anxiety Disorder. An additional number of six items assess symptoms of posttraumatic stress disorder (PTSD). The parents are asked to rate their children on a scale from 0 to 4 (where 0 = not at all true and 4 = very often true) for each item. Scale and total scores are computed by summing responses to the relevant items (Benga, inca, & Visu-Petra, 2010). Social Skills Rating System-Preschool level (Parent Form, Teacher Form). SSRS (Gresham & Elliott, 1990) consists of two summary scales: Social Skills and Behavior Problems. The Social Skills scale is comprised of four 10-item subscales: cooperation, assertion, responsibility, and self-control. Each item is rated on a 3point Likert scale, measuring the frequency of a specific behavior, where 0 = never and 2 = very often. The Behavior Problems summary scale consists of two subscales: Externalizing Problems consisting of 6 items and Internalizing Problems consisting of 4 items. Both subscales are rated on a 3-point Likert scale, where 0 = never and 2 = very often.
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The Childhood Autism Rating Scale (CARS; Schopler, Reichler & Renner, 1986) is a 15-item behavioural rating scale developed to identify children with autism, and to distinguish them from developmentally handicapped children without the autism syndrome. The CARS ratings can be made by diagnosticians, medical professionals, special educators, school psychologists, speech pathologists. The 15 items evaluate: relating to people, imitation, emotional response, body use, object use, adaptation to change, visual response listening response, taste, smell and touch response and use, fear and nervousness, verbal communication, nonverbal communication, activity level, level and consistency of intellectual response, general impressions. It further distinguishes children with autism in the mild to moderate rage from children with autism in the moderate to severe range. Asperger Syndrome Diagnostic Scale (ASDS; Myles, Bock & Simpson, 2001) is used for asssessment of individuals aged between 5 and 18 who manifest the characteristics of Asperger Syndrome. These 50 items were arranged into five categories to form subscales that provide the examiner with information of clinical interest. The general categories associated with characteristics of Asperger Syndrome, and evaluated through this instrument are: maladaptive (11 items), social (13 items), language (9 items), cognitive (10 items), and sensorimotor (7 items). All the items are summed to produce the Asperger Syndrome Quotient (ASQ). Consequently, the quotient score has strong diagnostic value in identifying individuals with Asperger Syndrome and is the only score to be used when determining the likelihood of Asperger Syndrome. The instrument can be completed by an individual who has a direct, sustained contact with the referred individual (e.g., teachers, parents, paraprofessionals, siblings, etc.). The Behaviour Assessment System for Children, Second Edition (BASC-2; Reynolds & Kamphaus, 2004) is a multidimensional system used to evaluate the behaviour and self perceptions of children and young adults aged between 2 to 25 years. It is multidimensional in that it measures numerous aspects of behaviour and personality, including positive (adaptative) as well as negative (clinical) dimensions: externalizing problems, internalizing problems, adaptability, agression, depression, anxiety, attention problems, executive functions, hyperactivity, etc. It also has a parent and a teacher checklist. In order to study the concurrent validation of ECI-4 subscales, for measures like SSRS (Gresham & Elliott, 1990), CARS (Schopler, Reichler & Renner, 1986), BASC-2 (Reynolds & Kamphaus, 2004) and ASDS (Myles, Bock & Simpson, 2001) the process of validation on Romanian population came to an end but there are not yet any published studies.

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DATA ANALYSIS Data analysis was conducted with SPSS for Windows software (version 13.0). Descriptive statistics were calculated on the participants that took part to the validation and standardization of the instrument. In order to test the relations among different variables, correlations were used (Spearman). T test were used for comparisons. Probability values are two-tailed and the significance level was considered at .05. RESULTS Criterion validity. For the Screening cutoff score were calculated the sensitivity and the specificity (see Table 3 ) for those disorders identified in the clinical sample (N=57). All the children from the clinical sample had a psychiatric diagnostic. The formula for obtaining the sensitivity index is: Sensitivity =

to be identified by ECI-4 as having that disorder). The formula for obtaining the specificity index is: Specificity =

B (the probability that an individual that has a disorder A B

C (the probability that an individual that doesnt have a CD

disorder to be identified by ECI-4 as not having that disorder). Real cases Non-real cases A (false negatives) C (true negatives) Dont have the disorder B (true pozitives) D (false pozitives) Have the disorder

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Table 3. Sensitivity and specificity in clinical group

The disorder Sensi tivity Teacher Checklist Speci The relative ficity rate of occurrence of the disorder in the sample .53 .83 .92 .73 .91 .91 .82 .12 .03 .01 .01 .00 .21 .01 .41 .00 .95 .86 .22 .01 .33 .00 1.00 .92 .22 .01 Parent Checklist Speci The relative ficity rate of occurrence of the disorder in the sample .65 .69 .86 .13 .03 .01 Both Checklists Speci The relative ficity rate of occurrence of the disorder in the sample .84 .91 .98 .13 .04 .02

Sensi tivity

Sensi tivity

A ADHD any type B Opozitional defiant disorder E-62-64 Generalized anxiety I Elimination problems J PTSD M Autistic disorder M Asperger syndrome

.85 .50 1.00 1.00 .58 1.00

.57 .50 .00

.42 .50 .00

As it can be seen from Table 3, the majority of the specificity values are higher than .80. This result means that ECI-4 is a specific instrument if we take into consideration APA norms Taking into account both checklists (for teachers and parents), specificity takes higher values. Sensitivity reached only modest values in general, probably because in the clinical sample there were few children for each diagnostic, and the values obtained for sensitivity and specificity should be taken into consideration with caution. Construct validity The construct validity has been investigated through Symptom severity score. A comparison among the means of the Symptom severity score between clinical (N=52) and non-clinical (N=95) sample was proceeded. The comparisons were made separately for teacher and parent checklists. In Tables 4-5 are presented the means, standard deviations, t values and level of significance for each disorder separately for teacher and parents forms. For the clinical sample the means are higher than in the non-clinical sample. It can be seen from those tables, the differences between means (t) are significant (p .05) for the majority of the categories evaluated. The same results were obtained regardless
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of informant (teacher or parent). As a conclusion, ECI-4 discriminates between clinical and non-clinical sample.
Table 4. The comparison among the means of the Symptom severity score between clinical and nonclinical sample, Parent Checklist Category A ADHD Innatentive Type A ADHD Hyperactiveimpulsive A ADHD combined B Opozitional defiant disorder C Conduct disorder Peer Conflict Scale D Separation anxiety E-62-64 Generalized anxiety F Major depressive disorder F Dysthymic disorder H Sleep disorders I Elimination problems J Posttraumatic stress disorder M Autistic disorder M Asperger syndrome Sample non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical N 91 49 91 49 91 49 91 48 91 49 91 49 91 48 91 49 91 49 91 49 91 49 91 47 91 48 90 49 90 49 m 6.86 13.10 6.98 11.51 13.84 24.61 4.67 8.27 1.56 1.69 1.92 3.71 4.34 6.08 5.18 8.59 4.09 7.07 3.32 5.31 2.31 3.12 .25 2.74 3.85 8.46 3.03 10.73 2.21 5.69 4.03 5.11 4.18 6.53 7.52 9.89 3.62 5.06 1.59 2.03 2.77 3.37 4.24 5.57 3.14 4.85 2.54 3.66 2.20 2.94 1.78 2.67 .98 3.77 2.64 3.81 3.35 7.53 2.45 4.71 t 7.945 4.399 6.663 4.376 0.428 3.184 1.896 4.454 5.071 4.150 1.916 4.450 7.483 6.805 4.829 Sig. (2tailed) .000 .000 .000 .000 .669 .002 .062 .000 .000 .000 .059 .000 .000 .000 .000

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Table 5. The comparison among the means of the Symptom severity score between clinical and non-clinical sample, Teacher Checklist
Category A ADHD Innatentive Type A ADHD hyperactiveimpulsive A ADHD combined B Opozitional Defiant Disorder C Conduct Disorder Peer Conflict Scale E-62-64 Generalized anxiety F Major Depressive Disorder F Dysthymic Disorder J Posttraumatic stress disorder M Autistic disorder M Asperger syndrome Sample non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical non-clinical clinical N 95 52 94 51 94 51 95 51 95 51 95 51 95 51 95 51 95 51 94 51 93 52 93 52 m 8.18 14.02 5.96 9.12 13.99 22.94 4.13 6.59 1.85 1.16 3.34 3.76 3.26 5.37 3.39 5.30 2.29 3.59 3.47 6.78 4.74 10.88 2.99 5.46 6.85 6.01 5.74 6.62 11.29 10.89 4.27 4.49 2.63 2.22 5.02 3.62 2.61 2.41 2.49 3.18 1.88 2.18 2.45 3.61 4.56 8.30 2.90 5.36 t 5.156 2.999 4.616 3.263 1.690 .537 4.776 3.719 3.521 5.863 4.936 3.086 Sig. (2tailed) .000 .003 .000 .001 .094 .592 .000 .000 .001 .000 .000 .003

Convergent validity was assessed by establishing the relationship between ECI-4 categories and other instruments that measure similar constructs. The correlation coefficients were processed separately for both parent and teacher forms. Pearson coefficients between Symptom Severity score and other instruments, varied in the medium range (see Table 6).

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Table 6. Correlation coefficients between ECI-4 and other instruments.

Category A ADHD Innatentive Type Parent Checklist The scale Problem behaviours subscale from SSRS Hyperactivity from BASC-2 Executive Functioning from BASC-2 Problem behaviours subscale from SSRS Hyperactivity from BASC-2 Executive Functioning from BASC-2 Problem behaviours subscale from SSRS Hyperactivity from BASC-2 Executive Functioning from BASC-2 Problem behaviours subscale from SSRS Problem behaviours subscale from SSRS Problem behaviours subscale from SSRS Aggression from BASC-2 Separation anxiety from Spence Preschool anxiety scale (Parent Report) Generalized anxiety from Spence Preschool anxiety scale (Parent Report) Depression from BASC-2 N, r N=124 r=.43** N=23 r=.53* N=23 r=.53* N=124 r=.46** N=23 r=.37* N=23 r=.44* N=124 r=.50** N=23 r=.48* N=23 r=.53* N=124 r=.54** N=125 r=.39** N=124 r=.61** N=23 r=.70** N=126 r=.71** N=123 r=.58** N=23 r=.63** N=23 r=.54* N=47 .29r.6 7* Depression from BASC-2 N=84 r=.65** N=84 r=.65** N=49 .28*r. 77* N=29 r=.78** Teacher Checklist The scale Problem behaviours subscale from SSRS Hyperactivity from BASC-2 Executive Functioning from BASC-2 Problem behaviours subscale from SSRS Hyperactivity from BASC-2 Executive Functioning from BASC-2 Problem behaviours subscale from SSRS Hyperactivity from BASC-2 Executive Functioning from BASC-2 Problem behaviours subscale from SSRS Problem behaviours subscale from SSRS Problem behaviours subscale from SSRS Aggression from BASC-2 N, r N=124 r=.73** N=84 r=.81** N=84 r=.76** N=124 r=.72** N=84 r=.77** N=84 r=.73** N=124 r=.77** N=84 r=.81** N=84 r=.78** N=124 r=.68** N=124 r=.59** N=124 r=.68** N=84 r=.81**

A ADHD hyperactiveimpulsive

A ADHD combined

B Opozitional Defiant Disorder C Conduct Disorder Peer Conflict Scale

D Separation anxiety E-62-64 Generalized anxiety F Major Depression Disorder F Dysthymic Disorder M Autistic Disorder M Asperger Syndrome

Depression from BASC-2 15 scale items from CARS

Depression from BASC-2 15 scale items from CARS ASDS

* p.05; ** p.01

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The results of the statistics presented in the table 6 indicate that in most of the situations, the values of the correlation coefficients are significant at p.05. Taking into account the correlations between M category and the 15 subscales of CARS, only one (i. e., level of activity) value of the correlation was not significant at p.05. All the significant values of correlation between ECI-4 categories and the other scales that measure similar constructs sustains the convergent validity of the instrument. Reliability Test-retest reliability. Test-retest reliability was measured for both teacher and parent forms of the ECI-4 at a 3 month interval on 40 children from a non-clinical group. Test-retest correlations were in the .66-.97 range for teacher checklist (see Table 7) and in the .35-.98 range for parent checklist. In almost all cases, the values of the correlations were significant at p.05. In only one situation, elimination problems, the value of the correlation was not significant at p.05, probably because during the period between test and retest (3 months) the symptoms might disappear as a consequence of participants maturization. It can be concluded that both teacher and parent checklist have good test-retest reliability and they are stable measures of the constructs evaluated.
Table 7. Test-retest correlations for the ECI-4, teacher and parent checklist The disorder Teacher Checklist A ADHD Innatentive Type .97* A ADHD Hyperactive-Impulsive .95* A ADHD combined .97* B Oppozitional Defiant Disorder .81* C Conduct disorder .68* Peer Conflict Scale .87* D Separation anxiety E-62-64 Generalized anxiety .97* F Major Depressive Disorder .91* F Dysthymic Disorder .91* G Social phobia .73* H Sleep disorders I Elimination problems .88* J Posttraumatic Stres Disorder .66* K Feeding problems M Autistic Disorder .92* M Asperger Syndrome .80* *p.05

Parent checklist .96* .94* .92* .95* .78* .98* .97* .92* .95* .94* .73* .84* .11 .71* .35* .91* .86*

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Inter-rater reliability. The inter-rater reliability was processed between the two informant sources: parents and teachers in both clinical (N=57, 63.2 % boys and 36.8% girls) and non-clinical (N=489, 50.1% boys and 49.9% girls) samples. For each disorder were considered only those children evaluated both by teacher and parents. The correlation coefficients were processed on Symptom Severity score.
Table 8. Inter-rater reliability coefficients between parents and teachers in both clinical and non-clinical sample

Category

Nonclinical sample .41*** .43*** .43*** .42*** .56*** .54*** .34*** .21*** .21*** .36*** .53*** .41***

Clinical sample .57*** .64*** .63*** .34* .01 .65*** .27* .44*** .43*** .48*** .76*** .66***

A ADHD Innatentive Type A ADHD Hyperactive-impulsive A ADHD combined B Oppositional defiant disorder C Conduct Disorder Peer Conflict Scale E-62-64 Generalized anxiety F Major Depressive Disorder F Dysthymic Disorder J Posttraumatic Stres Disorder M Autistic Disorder M Asperger Syndrome

*p.05; *p.01 ; ***p.001

For the non-clinical sample all the correlations were significant at p.001. In the clinical sample, the results indicate that the value of the Pearson correlation coefficients are significant at p .001 for most of the cases. In only two situations (i.e., oppositional defiant disorder and generalised anxiety) the level of agreement between the informants was significant at p.05 and in one case (i.e., conduct disorder) the level of agreement was not significant at p.05. This result might be a consequence of parents or teachers subjectivity in evaluating the childs behavior or a consequence of contextual behavior of the child.

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DISCUSSION We compared the means of the Symptom Severity scores between boys and girls in non-clinical sample. The total number of children integrated in the norm sample was 489. For the majority of the disorders evaluated by ECI-4, there is a significant difference between the means taking into consideration the sex. As a consequence, for the Symptom Severity scores, T scores were processed separately for boys and girls and for each type of informant (teacher and parent). Our results are similar with those obtained by the authors on the original sample. The findings of our study should be considered in the context of some limitations. Firstly, the number of participants in the clinical sample was relatively small and in the sample were not all the disorders evaluated by ECI-4 and as a conclusion we could not determine the sensitivity and specificity values for all disorders. Therefore those calculated must be interpreted with caution. Secondly, some of the persons in the clinical group might have unspecified associated psychological disorders, which could influence the results we obtained. For this reason some additional studies and data gathering are in process. CONCLUSION Our aim was to adapt, validate and create norms for ECI-4 on Romanian population. ECI-4 has proven to be a reliable and valid tool for assessing psychiatric disorder in children of Romania. Using ECI-4, we can evaluate the most prevalent psychiatric disorders in children. Screening instruments for mental health disorders in children reprezent a useful tool for mental health professionals to better understand their clients problems, to be more effective in clinical settings for assessment or treatment purposes. All the analyses undertaken regarding the psychometric characteristics of ECI-4 recommend it both for practical and research use. It can be used in the assessment process, research, intervention and follow-up of the treatment. To sum up, ECI-4, parents and teacher checklist show good psychometric properties. Based on these properties, we developed norms for preschool children of the Romanian population. However, there is a need to further evaluate this intrument, especially by further validation studies. As we also mentioned in Discussion section a shortcoming of this research is the fact that we could not obtain data for the specificity and sensibility indices for all categories evaluated by ECI-4. These data are being gathered and published in an upcoming study. However, results obtained untill now are encouraging. ECI-4 is simply a symptom questionnaire. It does not make diagnosis. Qualified professionals make diagnoses, and when done properly, the process involves collecting information from relevant sources and conducting thorough
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interviews with the child (when possible) and care providers. Because few clinicians are in the position to conduct clinical interviews with a patients teacher, we found the Teacher Checklist form of the ECI-4 to be a useful device for identifying patient symptoms in the kindergarden setting. The practical implications of our research are most relevant for mental health practitioners. We believe that a consistent evaluation of kindergarden children for psychiatric disorders is needed in order to prevent mental health problems. As a consequence, the aim of screening is not simply labelling children as with or without disorders, but rather promoting an early detection and intervention in such cases. REFERENCES
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Benga, O., inca, I., & Visu-Petra, L. (2010). Investigating the Structure of Anxiety Symptoms Among Romanian Preschoolers using The Spence Preschool Anxiety Scales. Cognition, Brain, Behaviour, 14 (2), 159-182. Gadow, K., & Sprafkin, J. (1997). Early Childhood Inventory-4. Norms Manual, Checkmate plus LTD. University of Stony Brook, New York, NY. Gadow, K., & Sprafkin, J. (2000). Early Childhood Inventory-4. Norms Manual, Checkmate plus LTD. Univeristy of Stony Brook, New York, NY. Gresham, F., & Elliott, S. (1990). Social Skills Rating System Manual. Circle Pines, MN: American Guidance Service. Hartung, C., & Lefler, E. (2010). Preliminary Examination of a New Mental Health Screener in a Pediatric Sample. Journal of Pediatric Health Care, 24(3), 168-175. Huffman, L., & Nichols, M. (2004). Early detection of young children's mental health problems in primary care settings. In R. DelCarmen-Wiggins, & A. Carter (Eds.), Handbook of infant, toddler, and preschool mental health assessment, Oxford, New York: Oxford University Press. Myles, B., Bock, S., & Simpson, R. (2001). Asperger Syndrome Diagnostic Scale. Examiners manual. Austin, Texas: Pro-Ed. Reynolds, C., & Kamphaus, R. (2004). Behavior Assessment System for Children Manual ( 2nd ed.). Circle Pines, MN: American Guidance Service Publishing. Schopler, E., Reichler, R., & Renner, B. (1986). The Childhood Autism rating Scale (CARS). Los Angeles: Western Psychological Services. Spence, S. H. (1998). A measure of anxiety symptoms among children. Behavior Research and Therapy, 36, 545566.

Cognition, Brain, Behavior. An Interdisciplinary Journal 15 (2011) 95-110