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Brown et al. International Journal of Mental Health Systems (2024) 18:21
https://doi.org/10.1186/s13033-024-00640-y International Journal of Mental
Health Systems
*Correspondence:
Felicity L. Brown
felicitylbrown@gmail.com
Full list of author information is available at the end of the article
Abstract
Background In humanitarian settings, brief screening instruments for child psychological distress have potential to
assist in assessing prevalence, monitoring outcomes, and identifying children and adolescents in most need of scarce
resources, given few mental health professionals for diagnostic services. Yet, there are few validated screening tools
available, particularly in Arabic.
Methods We translated and adapted the Child Psychosocial Distress Screener (CPDS) and the Pediatric Symptom
Checklist (PSC) and conducted a validation study with 85 adolescents (aged 10–15) in Lebanon. We assessed internal
consistency; test-retest reliability; convergent validity between adolescent- and caregiver-report and between
the two measures; ability to distinguish between clinical and non-clinical samples; and concurrent validity against
psychiatrist interview using the Kiddie Schedule for Aective Disorders and Schizophrenia.
Results The translated and adapted child-reported PSC-17 and PSC-35, and caregiver-reported PSC-35 all showed
adequate internal consistency and test-retest reliability and high concurrent validity with psychiatrist interview and
were able to distinguish between clinical and non-clinical samples. However, the caregiver-reported PSC-17 did
not demonstrate adequate performance in this setting. Child-reported versions of the PSC outperformed caregiver-
reported versions and the 35-item PSC scales showed stronger performance than 17-item scales. The CPDS showed
adequate convergent validity with the PSC, ability to distinguish between clinical and non-clinical samples, and
concurrent validity with psychiatrist interview. Internal consistency was low for the CPDS, likely due to the nature
of the brief risk-screening tool. There were discrepancies between caregiver and child-reports, worthy of future
investigation. For indication of any diagnosis requiring treatment, we recommend cut-os of 5 for CPDS, 12 for child-
reported PSC-17, 21 for child-reported PSC-35, and 26 for caregiver-reported PSC-35.
Validation of Arabic versions of the child
psychosocial distress screener and pediatric
symptom checklist for young adolescents
living in vulnerable communities in Lebanon
Felicity L.Brown1,2*, FrederikSteen1, KarineTaha3, Gabriela V.Koppenol-Gonzalez1, MayAoun3, RichardBryant4 and
Mark J D.Jordans1,2
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Brown et al. International Journal of Mental Health Systems (2024) 18:21
Background
Global rates of forced displacement due to armed con-
flict are at unprecedented levels [1]. Children’s exposure
to armed conflict leads to increased risk of psychologi-
cal distress and disorders [2]. ere is increasing focus
on the importance of providing mental health care to
children and adolescents in these contexts, however
significant barriers to service provision exist, includ-
ing the availability of mental health specialists to assist
in assessment, diagnosis, and treatment [3]. In order to
adequately understand rates of psychological distress,
accurate identification of those needing treatment, and
the effectiveness of services, there is a need for adequate
self-report measurement tools that can be administered
by non-professionals.
e majority of validated psychological assessment
tools are developed in high income countries. While
there is increasing use of these tools in different cul-
tural and linguistic populations, their cultural and con-
textual validity is often not adequately considered [4,
5]. In humanitarian contexts, assessing the validity of
tools is particularly important, for several reasons: (i)
the presence of diverse and complex situational stress-
ors; (ii) varying cultural backgrounds of communities;
(iii) increased vulnerability for psychological distress
coupled with limited service availability, making accu-
rate identification of those needing treatment vital; and
(iv) the potential for non-adapted tools to inflate rates
of clinical disorders, or to miss other valid complaints.
Furthermore, many existing tools are diagnosis-specific,
meaning that multiple tools are required to detect treat-
ment needs across the spectrum of possible disorders.
is is infeasible in low resource settings, where broad
measures of distress may be better fit to capture the
range of complaints requiring treatment [6]. As there is
a growing move towards transdiagnostic interventions
that are applicable to a range of symptoms of distress and
can be delivered by non-specialists [6], there is a need for
accompanying broad screening tools.
A large number of refugees globally are Arabic speak-
ing, with 6.7million refugees from Syria since the onset
of the civil war constituting the largest refugee group in
2020 [1]. Translating measures into Arabic poses par-
ticular challenges. Most available translations use written
modern standard Arabic, which can diverge from dialects
spoken in different regions, leading to issues for stan-
dardization, validity, and reliability of measures. Since the
majority of research involving Arabic-speaking people
relies on self-report measures developed and normed
internationally, it is essential that careful considerations
are incorporated in decisions around translation, adapta-
tion, and norming, to ensure methodological validity and
reliability of implementation [5, 7].
In this study we aimed to evaluate the psychometric
properties of two translated and adapted psychological
distress screeners in Lebanon- the Child Psychosocial
Distress Screener (CPDS) [8] and adolescent- and care-
giver-report 17- and 35- item versions of the Pediatric
Symptom Checklist (PSC) [9].
Methods
Design
We systematically translated and adapted the tools and
administered them with 85 adolescents (age 10–15) and
their caregivers, followed by a structured clinical inter-
view conducted by a psychiatrist (n = 83). A sub-sam-
ple (n = 58) of adolescents repeated the two measures
approximately 10 days later, with no intervention pro-
vided in between. First, we assessed internal consistency
and test-retest reliabilities. Second, we assessed conver-
gent validity between adolescent and caregiver report and
between the CPDS and PSC. ird, we examined known-
groups validity by testing the ability of the measures to
distinguish between clinical and non-clinical groups of
adolescents. Finally, we assessed concurrent validity by
comparing the scores on the measures with a ‘gold stan-
dard’ semi-structured clinical interview for psychiatric
disorder. We were interested in three types of ‘caseness’:
(i) whether the psychiatrist detected any diagnosis, (ii)
whether the psychiatrist indicated that the adolescent
needed treatment, and (iii) both diagnosis and need for
treatment. e study design is depicted in Fig.1 below.
Ethical approval was obtained from St Joseph’s University
Beirut (USJ-2017-24).
Setting
Lebanon is a middle-income, Arabic-speaking country
that has experienced prolonged internal and external
conflicts and hosts the highest number of refugees per
capita globally [1]. We conducted our study via three
community-based organisations partnering with War
Child Alliance, in Chatila Palestinian camp in Beirut, and
Mina and Beb el Ramel in Tripoli.
Conclusions The Arabic PSC and CPDS are reliable and valid instruments for use as primary screening tools in
Lebanon. Further research is needed to understand discrepancies between adolescent and caregiver reports, and
optimal methods of using multiple informants.
Keywords Child psychosocial distress screener, Pediatric symptom checklist, Psychosocial screening, Lebanon,
Validation, Adolescence
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Brown et al. International Journal of Mental Health Systems (2024) 18:21
Recruitment, sample size, inclusion criteria
Participants were adolescents aged 10 to 15 years of Leb-
anese, Syrian, Palestinian, or Egyptian nationality. We did
not select adolescents based on clinical status but aimed
to achieve a representative sample of those attending ser-
vices. Recruitment was conducted via regular outreach
approaches, which target adolescents living in areas of
high adversity and vulnerability. Adolescents displaying
significant cognitive disability or psychosis via psychia-
trist assessments were excluded from analysis, to avoid
compromising reliability of the self-report findings.
Measures
Pediatric symptom checklist
e PSC comprises 35 symptoms (including internalis-
ing, externalising, somatic, social, and academic difficul-
ties) rated for frequency of occurrence on a three-point
scale from 0 (never) to 2 (often) [9]. e total score ranges
from 0 to 70. e PSC-35 has shown high internal consis-
tency, test-retest reliability, and strong agreement, speci-
ficity and sensitivity compared to validated measures or
clinician assessments [10]. For children aged 6–16 years
the standard cut-off score on the caregiver-report tool is
28 or above; the PSC does not provide a diagnosis, but
instead indicates emotional and behavioural problems
that may warrant further clinician assessment. It has
demonstrated feasibility and sustainability as a primary
screening tool; however, developers stress the need to
determine valid cut-off scores for new populations [9].
Less research exists on child-report versions; one study
found that PSC child-report significantly correlated with
caregiver and teacher report of child dysfunction, and
with child-reported symptoms of depression and anxi-
ety on other measures [11]. Of those identified as need-
ing follow-up on the child-report, 71% had not been
identified using the caregiver-reported PSC, highlighting
the importance of youth-report measures. e recom-
mended cut-off from this study in a low-income popula-
tion in the USA is 30.
A shorter 17-item checklist, consisting of a sub-set of
items from the longer scale, has been developed and the
caregiver-report version has shown high agreement with
clinician diagnoses, performing as well as existing child-
reported screeners, with the exception of identifying
anxiety disorders [12]. Recommended cut-offs for child
and caregiver-report versions are 15 and above. One vali-
dation study conducted in Turkey found strong internal
consistency, test-retest reliability, and discriminant and
concurrent validity when compared with scores on the
Child Behaviour Checklist [13], but found a cut-off of 12
to be optimal.
We translated and adapted the PSC to Arabic for use
in Lebanon, following a systematic process based on best
practice [14]. is involved: (i) forward and back trans-
lation to modern standard Arabic by independent trans-
lators; (ii) translation workshop with bilingual Lebanese
professionals in Lebanon; (iii) forward and back transla-
tion to simple spoken Arabic (considered suitable for
Syrian and Lebanese populations) by independent trans-
lators; (iv) translation workshop with bilingual Lebanese
professionals in Lebanon; (v) cognitive interviewing with
target Arabic-speaking adolescents in Lebanon, including
Syrian refugees; (vi) a translation workshop with bilingual
Lebanese team members to review necessary translation
changes needed; vi) pilot testing through a pre-post study
of an educational intervention in Lebanon; (vii) further
cognitive interviewing; (viii) a further translation work-
shop to further refine the translations; (ix) final adjust-
ments to translation of the items; (x) back translation by a
bilingual psychologist not involved in prior steps; xi) final
agreement by two bilingual psychologists. Items between
the 17- and 35-item versions are identical, and adoles-
cent- and caregiver-reported items only differ on whether
they refer to ‘you’ or ‘your child’, therefore any changes
made on one version of the measure were also reflected
in other versions.
e main changes were:
Fig. 1 Design of validation study for Pediatric Symptom Checklist and Child Psychosocial Distress Screener for adolescents in Lebanon
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Brown et al. International Journal of Mental Health Systems (2024) 18:21
1. Item 1 (complains of aches and pains) and Item
3 (tires easily, has little energy)- were switched
in order, as starting with a somatic symptom was
confusing for adolescents.
2. Item 7- the idiom ‘like driven by a motor’ was not
applicable and replaced by ‘feels like she/he can’t stop
moving’.
3. Items 5 and 6- references to teachers and schools
were expanded to include other adults and other
daily activities, to be more applicable to out-of-
school adolescents.
4. Item 13- the concept of ‘hopeless’ is not easily
understood in Arabic, and this question was
reframed and reversed to ‘thinks that the coming
days will be better’.
5. Items 29 (does not listen to rules) and Item 31
(does not understand other people’s feelings)- were
reversed, as the negative framing was complex to
understand in Arabic.
Child Psychosocial distress screener
e CPDS was developed in the context of a psychoso-
cial program for children in four conflict-affected coun-
tries [15]. It is a primary screening tool for children
aged 8–14 years, that assesses psychosocial distress, as
opposed to specific disorders, promoting early detection
of children in need for psychosocial care. e tool con-
sists of 5 child-reported items, and 2 caregiver-reported
items, with general questions which are then elucidated
using probes developed for the specific context; for
example the first question ‘Did you experience any aver-
sive events?’, is then followed by locally relevant exam-
ples. Higher scores indicate more psychosocial distress.
e CPDS has robust cross-cultural construct validity
[4] and has been validated in Burundi samples, with an
optimal cut-off of 8, with diagnostic sensitivity between
0.84 and 0.94 and specificity between 0.60 and 0.75 [7].
In Lebanon, we developed probes directly from findings
of a rapid qualitative assessment [16], using the Arabic
words used by respondents. e general questions were
translated initially following forward and back translation
to simple spoken Arabic (considered suitable for Syrian
and Lebanese populations) by independent translators,
followed by a translation workshop with bilingual profes-
sionals. e questions and the probes were then refined
via the following iterative steps (i) cognitive interview-
ing with target adolescents (Syrian and Lebanese); (ii) a
translation workshop to review necessary translation
changes needed; (iii) further cognitive interviewing;
(iv) a further translation workshop to further refine the
translations; (v) final adjustments to translation of the
items; (vi) back translation by a bilingual psychologist not
involved in prior steps; (vii) final agreement by two bilin-
gual psychologists.
Kiddie schedule for aective disorders and schizophrenia
e Kiddie Schedule for Affective Disorders and Schizo-
phrenia (KSADS) [17] is a comprehensive semi-struc-
tured clinical interview designed to identify mental
disorders in children according to Diagnostic and Sta-
tistical Manual of Mental Disorders Fourth Edition [18]
classifications. e instrument was translated to Arabic
by Un Ponte Per in Iraq. ree psychiatrists in Lebanon
received three half-day Skype training sessions with the
tool developers at STAR Center, University of Pittsburgh,
and regular supervision via four Skype sessions. Dur-
ing the training sessions, they reviewed terminology and
determined adjustments that may be needed for local
dialects.
Assessments started with an introduction to build rap-
port and obtain biographical information. e KSADS
interview was conducted, including assessment of
nonspecific distress, functioning, coping and support
mechanisms, and contextual information. Additional
information was obtained from caregivers when required.
Psychiatrists recorded the presence of current diagno-
ses (definite, probable, or partial remission), whether
participant data should be excluded due to psychosis or
cognitive disability, and whether the adolescent required
treatment. We focused only on current symptoms, rather
than lifetime diagnoses. We assessed for substance use
disorders but did not code tobacco use disorder as a diag-
nostic category for analysis. We omitted assessment of
enuresis, encopresis, mania, anorexia, bulimia, conduct
disorder, and tic disorder. is was determined based on
cross-cultural relevance, and the extent to which these
would be captured on self-report.
Procedure
e procedure is illustrated in Fig. 1. First, caregivers
provided written informed consent for their participa-
tion and their adolescents’, then adolescents provided
assent. e CPDS and then the PSC were administered
via a one-to-one interview with a trained research assis-
tant who read the questions, provided respondents with
pictorial Likert scales to aid responding, and recorded
responses in Kobo data collection software (Adolescent
Assessment 1 and Caregiver Assessment).
Adolescents were subsequently interviewed by a psy-
chiatrist on a separate day within two weeks of the first
assessment (Psychiatrist Interview). Psychiatrists were
blind to questionnaire results. Two adolescents were
unable to attend interviews due to scheduling difficul-
ties. Psychiatrists recorded diagnosis/es (if any), and a
dichotomous response on treatment indication (yes/
no). Case-consensus meetings were held with the three
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Brown et al. International Journal of Mental Health Systems (2024) 18:21
psychiatrists for nine interviews, whereby one psychia-
trist presented their case findings in detail, and the other
two psychiatrists provided blind opinions on the cases on
diagnoses and treatment indication.
Approximately 14 days after assessment 1 (M = 14.4
days, range = 10–17 days), and after the psychiatrist
interview, a subsample of adolescents took part in a fol-
low up assessment (Adolescent Assessment 2). Conve-
nience sampling was used, with all adolescents invited to
an assessment day, and interviews conducted with those
attending.
No financial incentives were provided for participating.
A small refreshment was provided to adolescents and
caregivers at each assessment, and a small reimburse-
ment was provided to cover transportation costs.
Adolescents requiring urgent treatment were referred
following national referral pathways and organizational
procedures. Eligible adolescents were also invited to par-
ticipate in a pilot of a new psychological intervention.
Statistical analysis
Preliminary analyses and psychometric properties
From Adolescent Assessment T1, Caregiver Assessment,
and Psychiatrist interviews, we present demographics
data and diagnostic and treatment status descriptively. To
assess internal consistency of the PSC and the CPDS, we
calculated Cronbach’s alpha for each measure. Confirma-
tory factor analysis was not considered to be valid given
the small sample size and properties of the dataset [19].
Reliability and validity analyses
We examined convergent validity via Pearson correla-
tions between PSC child, CPDS child, PSC caregiver,
CPDS caregiver, and CPDS total scores. We calculated
test-retest reliability for 58 cases using Intraclass Cor-
relation Coefficients (ICC). We considered a coefficient
below 0.40 poor, 0.40 to 0.59 fair, 0.60 to.74 good; and
0.75 to 1.00 excellent [20]. We conducted between-group
t-tests to compare PSC and CPDS mean scores between
groups indicated for treatment or not, and between
groups with any diagnosis versus none.
We calculated receiver operating characteristic (ROC)
curves and examined area under the curve (AUC) for:
1. Overall accuracy of CPDS to distinguish caseness.
2. Overall accuracy of PSC-35 child- and caregiver-
report to distinguish caseness.
3. Overall accuracy of PSC-17 child- and caregiver-
report to distinguish caseness.
We considered caseness in multiple ways.
1. Any diagnosis included in the KSADs.
2. Treatment indication.
3. Any diagnosis plus treatment indication.
4. Internalizing diagnosis (removing ADHD and ODD).
5. Internalizing diagnosis plus treatment indication.
For each measure we also calculated positive predictive
value (PPV; proportion of positive test results for true
caseness) negative predictive value (NPV; proportion of
negative test results for true non-caseness), optimal cut-
offs, and sensitivity and specificity.
Handling missing data
We noted a very small proportion of missing data, with
the exception of school-related items which were not
relevant for many out-of-school adolescents. Of all the
items at T1 there were 9 items with 1 to 5 missing values
(1.2 to 6.1%) and one item with 14 missing values (17.1%).
Analyses were conducted using replacement with the
proportion score of the answered items and multiple
imputation with three data sets. Findings did not differ
significantly; therefore, multiple imputation analyses are
reported.
Results
Participants
Eighty-five adolescents completed the initial assessment
with their caregivers. Eighty-three adolescents com-
pleted assessments with psychiatrists. We excluded three
participants from analyses, one due to likely psychotic
symptoms, one due to likely significant cognitive impair-
ment, and one due to both. irty-three adolescents were
assessed as having a diagnosis (probable, definite, or in
partial remission). Eighteen were indicated as needing
psychiatric or psychological treatment. Demographics
and diagnoses are shown in Table1 below.
e sample consisted predominantly of Syrian refugees,
slightly more females than males, and mostly adolescents
not attending school. e most common diagnoses were
major depressive disorder (15%) and separation anxiety
disorder (22%), followed by simple phobias (10%), social
phobia (10%), and generalized anxiety disorder (9%).
As shown in Table2, the PSC-35 child and caregiver
versions both had good internal consistency, and the
PSC-17 child and caregiver versions had adequate inter-
nal consistency. Internal consistency for the CPDS was
unacceptable, but this scale consists of only five adoles-
cent-reported items plus two caregiver-reported item,
and is designed to indicate treatment need, rather than
assess one construct. Adolescent-reported PSC and
CPDS scores correlated highly, as did caregiver-reported
PSC and CPDS scores, but adolescent and caregiver
reports did not correlate with each other. Test-retest reli-
ability had fair to good clinical significance for adolescent
measures [20].
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Brown et al. International Journal of Mental Health Systems (2024) 18:21
ere was a significant difference in scores on the
CPDS, adolescent-reported PSC-35, adolescent-reported
PSC-17, and caregiver-reported PSC-35 for adolescents
indicated for treatment versus those not indicated for
treatment, and for adolescents assessed as having a diag-
nosis versus not having a diagnosis (See Table3). ere
was no significant difference between groups on care-
giver-reported PSC-17.
As shown in Tables 4 and 5, the optimal cut-off for
the PSC measures varied depending on the criterion
for ‘caseness’ and whether adolescent-reported or care-
giver-reported. For CPDS, a cut-off of 5 was found to
be optimal. It should be noted that a cut-off of 4 had
higher sensitivity (.82), however specificity was reduced
at this cutoff and overall accuracy was lower. e CPDS
had adequate AUC. AUCs were higher for adolescent-
reported PSC-17 (.80-.83) and PSC-35 (.83-.85) than
caregiver PSC-17 (.55-.61) and PSC-35 (.65-.73) and were
higher for 35-item scales than 17-item scales.
Discussion
We found that the translated and culturally adapted ver-
sions of the CPDS, adolescent-reported PSC-17 and PSC-
35, and caregiver-reported PSC-35 scales have sound
psychometric properties and criterion validity when
delivered by non-specialists for adolescents aged 10–15
years living in Lebanon. ey showed adequate test-retest
reliability, ability to distinguish between clinical and
non-clinical samples, and high concurrent validity com-
pared to psychiatrist assessment. e caregiver-reported
PSC-17 did not demonstrate adequate performance in
this population, and both the 17- and 35-item adoles-
cent-reported PSCs outperformed caregiver-reported
versions. Similarly, 35-item PSCs showed stronger per-
formance than shorter 17-item scales. While the PSC
scales showed adequate internal consistency, the CPDS
did not.
Table 1 Demographics of adolescent sample in lebanon
N%
Sex Female 50 61
Male 32 39
Age 10 20 24
11 22 27
12 19 23
13 12 15
14 7 9
15 2 2
Nationality Lebanese 12 15
Syrian 67 82
Palestinian 2 2
Egyptian 1 1
Attends school Yes 30 37
No 52 63
Generates income Yes 6 7
No 76 93
Responding
caregiver
Mother 73 89
Father 7 9
Other 2 2
Diagnosis Major depressive disorder 12 15
Dysthymia 3 4
Adjustment disorder (depression) 3 4
Adjustment disorder (anxiety) 2 2
Panic disorder 1 1
Separation anxiety disorder 18 22
Avoidant disorder of childhood 2 2
Simple phobia 8 10
Social phobia 8 10
Agoraphobia 1 1
Overanxious 5 6
Generalised anxiety disorder 7 9
Obsessive compulsive disorder 1 1
Post-traumatic stress disorder 4 5
Acute stress disorder 1 1
Attention decit hyperactivity disorder 4 5
Oppositional deant disorder 2 2
Table 2 Psychometric properties, correlations, and test-retest reliability of PSC and CPDS
Cron-
bach’s
alpha
Test-retest
reliability
(ICC)
PSC-35
Child
PSC-17
Child
PSC-35
Caregiver
PSC-17
Caregiver
CPDS
Child
CPDS
Caregiver
CPDS
Total
PSC-35 Child 0.80 0.69
(good)
0.18 0.56** 0.19 0.59**
PSC-17 Child 0.61 0.58
(fair)
0.09 0.46** 0.18 0.50**
PSC-35 Caregiver 0.80 n/a − 0.08 0.47** 0.14
PSC-17 Caregiver 0.72 n/a − 0.11 0.36** 0.06
CPDS Child 0.66 0.63
(good)
− 0.04 0.90**
CPDS Caregiver n/a n/a 0.41**
CPDS Total 0.49 n/a
Note PSC, Ped iatric Symptom Checklis t; CPDS, Child Psychosocia l Distress Screener ; ICC, Intraclass Correlat ion Coecient
** p < .01
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Brown et al. International Journal of Mental Health Systems (2024) 18:21
e CPDS may have had lower internal consistency
due to the fact that it incorporates contextual challenges
into one measure of ‘psychosocial risk’, rather than mea-
suring diagnostic symptoms as one underlying ‘construct’.
Furthermore, it is a very brief multi-source instrument,
with some items reported by child and some by caregiver,
which is likely to impact internal consistency. Given that
the benefit of the screening tool is the brief nature and
contextual focus, the low internal consistency considered
alongside sound validity, may not indicate poor perfor-
mance for the intended purpose.
To identify adolescents in need of treatment, we rec-
ommend a total cut-off score of 5 on the CPDS. For PSC
measures, the cut-offs vary depending on the respondent,
and the desired criterion. We recommend a cut-off of 12
on the adolescent-reported PSC-17, as the optimal cut-
off for an adolescent needing psychological treatment, an
adolescent indicated as having any diagnosis and need-
ing treatment, and an adolescent indicated as having an
internalising diagnosis and needing treatment. We rec-
ommend a cut-off of 21 on the adolescent-reported PSC-
35, as the optimal cut-off for an adolescent indicated as
having any diagnosis and needing treatment, and an ado-
lescent indicated as having an internalising diagnosis and
needing treatment. For caregiver-reported PSC-35, we
recommend a cut-off of 21, as indicating an adolescent
needing treatment, and an adolescent having an internal-
izing diagnosis and needing treatment. While sensitivity
and specificity at these cut-offs was considered optimal,
false positives for treatment indication may be elevated
(indicated by the low PPVs) when using these tools. ey
should be used as a first step to indicate further assess-
ment, rather than being considered as diagnostic tools.
Furthermore, uncorrected prevalence rates based on
these tools may over-estimate treatment need.
ese cut-offs are lower than generic cut-offs recom-
mended, (15 for PSC-17 and 28 for PSC-35 caregiver-
reports) but match the cut-off for the PSC-17 identified
in a Turkish sample [13]. Stoppelbein and colleagues
[21] similarly found a PSC-17 cut-off of 12 in a sample of
youth in the USA, with systematically different response
patterns between Caucasian versus African American
youth, possibly due to cultural norms in responding. Our
lower cut-off score may be due to under-reporting of
symptoms on an assessment, given that stigma related to
mental health concerns is a widely acknowledged prob-
lem in this region [22]. It is possible that psychiatrists
were able to elicit more disclosure of symptoms through
interviews. Nonetheless, our experience highlights the
importance of identifying culturally and contextually rel-
evant norms to prevent over- or under-identification.
In our sample, adolescent-reported and caregiver-
reported scales did not correlate. Caregiver-reported
scales demonstrated lower concurrent validity with psy-
chiatrist interviews, possibly since interviews were con-
ducted solely with adolescents. Similar findings have
been found in previous research using the PSC [23] and
other scales (24–25) and discrepancies between care-
giver and adolescent reports may predict future adoles-
cent internalizing symptoms and functioning (24–25).
In this study caregiver-reported questionnaires had
particularly low AUC for internalizing disorders, pos-
sibly indicating that caregivers have less knowledge of
internalizing symptoms as compared to externalizing
symptoms. Future research will be important to further
understand the reasons and implications for discrepan-
cies in Lebanon.
In this sample, 40% of adolescents were assessed by
psychiatrists as meeting criteria for at least one diagnosis,
and 22% were considered to be in need of mental health
treatment. A recent meta-analysis found that approxi-
mately 20% of individuals living in conflict-affected areas
meet diagnostic criteria for a common mental disorder
at any given time [2]. e high prevalence of diagnosable
disorders found among adolescents of mixed nationali-
ties in this study, though a small and non-representative
sample, are in line with extremely high rates of psycho-
logical symptoms reported among Syrian refugees [26].
Our findings support the importance of incorporating
generic screening measures for children and adolescents
affected by armed conflict and adversity, beyond just
trauma-related symptoms, and providing evidence-based
psychological treatments that address the diverse chal-
lenges experienced. In our study, the majority of diag-
noses were not trauma-focused, but rather mood and
anxiety focused. While our study was not designed to
determine prevalence rates, diagnoses of post-traumatic
stress disorder were substantially lower than those found
Table 3 Results of between group t-tests on PSC and CPDS scores for children identied as “Cases” or “Non-Cases”
Treatment Indicated? Diagnosis?
Case (M) Non-Case (M)t-test Case (M) Non-Case (M)t-test
PSC-35 Child 25.56 14.67 t (21.6)= -4.83, p < .001 22.30 13.48 t (78)= -5.60, p < .001
PSC-17 Child 13.39 8.10 t (78)= -5.61, p < .001 11.76 7.57 t (78)= -5.12, p < .001
PSC-35 Caregiver 24.85 19.47 t (78)=-2.30, p < .05 23.27 18.86 t (78)=-2.21, p < .05
PSC-17 Caregiver 13.65 12.00 t (57)=-1.01, p = .30 12.93 12.00 t (57)=-0.66, p = .51
CPDS 6.11 3.76 t (78)= -3.58, p < .001 5.76 3.26 t (78)= -4,73, p < .001
Note PSC, Ped iatric Symptom Checklis t; CPDS, Child Psychosocia l Distress Screener
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 8 of 10
Brown et al. International Journal of Mental Health Systems (2024) 18:21
in epidemiological studies [26], suggesting the need for
further research to understand the application of such
diagnostic categories in diverse settings. While direct
exposure to war-related trauma undoubtedly increases
risks for a range of psychological symptoms, trauma-
focused models neglect a range of important etiological
factors including pervasive daily stressors, adverse family
events and community environments, and do not address
the broad spectrum of clinical presentations that are
likely to arise [27]. Further, the use of non-specific dis-
tress screeners has been advocated in other settings, to
identify broadly defined distress [28].
Our results indicate the utility of these translated and
adapted tools as primary screeners with adolescents in
Lebanon. e translated instruments overcome issues
with other tools that commonly use modern standard
Arabic, which can be misunderstood by respondents, or
may be converted non-systematically to spoken dialect
by assessors as they are delivering it, both of which com-
promise reliability and validity.
One limitation of our study was the relatively small
sample size (n = 80). While comparable to similar studies
(n = 65) [8, 29], more cases would have increased statisti-
cal power. Future research should conduct confirmatory
factor analyses and other more advanced analyses using
larger samples [5]. Additionally, test-retest assessments
were conducted with a sub-sample of adolescents avail-
able on second assessment day, and we did not follow up
further with those who did not attend. erefore, our re-
test sample may not have been representative of the full
sample. We could not ensure that the same assessor com-
pleted the second assessment with adolescents, which
may have added variance in our test-retest analyses.
Additionally, adolescents participating in the study were
already engaged in services, and therefore may have felt
more comfortable disclosing problems, or may not have
been representative of a general community sample. It
will be important for future research to explore the use
of these tools in different settings, including during a first
contact with children and adolescents, to ensure general-
izability of findings.
Conclusions
In low resource settings, a huge mental health treatment
gap exists, largely owing to unavailability of profession-
als to assess and identify those needing treatment, and to
provide those treatments. Furthermore, there is a dearth
of culturally validated screening instruments. Our study
indicates the feasibility of conducting screening by non-
professionals in Lebanon, using short, culturally-adapted
instruments, making early detection of adolescents need-
ing psychological treatment possible. is enables actors
to: (i) identify the scope of mental health needs in a
population; (ii) identify adolescents most in need of the
Table 4 Area under the curve and predictive properties for optimal cut-o scores for PSC and CPDS
KSADS- any diagnosis KSADS- treatment indicated KSADS- diagnosis and treatment indicated
Measure AUC Cut oaSens Spec PPV NPV AUC Cut oaSens Spec PPV NPV AUC Cut oaSens Spec PPV NPV
PSC-35 Child 0.83 17 0.82 0.70 0.66 0.85 0.83 16 0.83 0.55 0.35 0.92 0.85 21 0.71 0.86 0.58 0.92
PSC-17 Child 0.80 10 0.61 0.72 0.61 0.72 0.83 12 0.67 0.90 0.67 0.90 0.83 12 0.71 0.91 0.67 0.92
PSC-35 Caregiver 0.65 19 0.78 0.51 0.53 0.77 0.71 21 0.78 0.61 0.37 0.90 0.73 26 0.65 0.81 0.48 0.90
PSC-17 Caregiver 0.55 11 0.63 0.41 0.53 0.52 0.61 12 0.65 0.55 0.37 0.79 0.61 12 0.63 0.54 0.33 0.79
CPDS 0.76 5 0.62 0.79 0.67 0.75 0.75 5 0.69 0.71 0.41 0.89 0.77 5 0.73 0.71 0.41 0.91
Note KSADS, Kiddie Schedule for Aective Disorders and Schizophrenia; PSC, Pediatric Symptom Checklist; CPDS, Child Psychosocial Distress Screener; AUC, Area under the curve; Sens, Sensitivity; Spec, Specicity; PPV,
Positive Predictive Value; NPV, Negative Predictive Value
aoptimal cut-o determined through examining Receiver Operating Curve Tabs
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 10
Brown et al. International Journal of Mental Health Systems (2024) 18:21
limited services available; and (iii) adequately measure
the effectiveness of these services. e use of a transdiag-
nostic measure of distress, rather than a narrow measure
of a particular diagnosis, provides a more flexible and
practical approach in a setting where mental health needs
are diverse and complex.
Abbreviations
CPDS Child Psychosocial Distress Screener
PSC Pediatric Symptom Checklist
K-SADS Kiddie Schedule for Aective Disorders and Schizophrenia
ICC Intraclass Correlation Coecients
ROC Receiver Operating Characteristic
AUC Area Under the Curve
Acknowledgements
Our utmost gratitude goes to the adolescents and caregivers who dedicated
their time to take part in the assessments. Additionally, we would like to
thank the War Child Lebanon team and community-based organisations who
facilitated the outreach and participation of adolescents and caregivers in the
activities. We greatly appreciate the professionalism, compassion, dedication,
and exibility of the psychiatrists who completed the interviews: Christina
Aramouny, Sayed Jreige, and Caroline Girgis Tarraf. Finally, thank Candice
Biernesser, Maria Anderson, and Madeline Nassida from the University of
Pittsburgh for providing training and supervision in the KSADs.
Author contributions
The study was conceptualised and designed by F.B., M.J., R.B., and M.A. K.T., F.S.,
and F.B. coordinated the implementation of the study and collection of data
in Lebanon. G.K. and F.B. conducted data analysis. F.B. lead the writing of the
manuscript, with contributions from all authors. All authors revised the paper
critically for important intellectual content and provided nal approval of the
version to be published. F.B., M.J., G.K., F.S., and K.T. had full access to the data
and take responsibility for the integrity of the data and the accuracy of the
data analysis.
Funding
Funding provided by World Vision Canada (administered via University of New
South Wales) and War Child Alliance.
Data availability
The datasets used and/or analysed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethical approval was obtained from St Joseph’s University Beirut (USJ-2017-24).
All research was conducted in accordance with the Declaration of Helsinki.
Written parental consent and child assent were obtained from all participants.
Competing interests
The authors have declared that they have no competing or potential conicts
of interest.
Author details
1Research and Development Department, War Child Alliance,
Helmholtzstraat 61G, Amsterdam, The Netherlands
2Amsterdam Institute of Social Science Research, University of
Amsterdam, Amsterdam 1098LE, The Netherlands
3War Child Alliance Lebanon, Beirut, Lebanon
4School of Psychology, University of New South Wales, Sydney, NSW,
Australia
Received: 10 July 2022 / Accepted: 20 May 2024
Table 5 Area under the curve for internalizing diagnoses only and predictive properties for optimal cut-o scores for PSC and CPDS
KSADS any internalising diagnosis KSADS any internalising diagnosis and treatment indicated
Measure AUC Cut oaSens Spec PPV NPV AUC Cut oaSens Spec PPV NPV
PSC-35 Child 0.83 17 0.82 0.70 0.66 0.85 0.85 21 0.71 0.86 0.58 0.92
PSC-17 Child 0.80 10 0.61 0.72 0.61 0.72 0.83 12 0.71 0.91 0.67 0.92
PSC-35 Caregiver 0.65 19 0.78 0.51 0.53 0.77 0.73 21 0.82 0.61 0.37 0.93
PSC-17 Caregiver 0.55 11 0.63 0.41 0.53 0.52 0.61 12 0.63 0.54 0.33 0.79
CPDS 0.76 5 0.62 0.79 0.67 0.75 0.77 5 0.73 0.71 0.41 0.91
Note KSADS, Kiddie Schedule for Aective Disorders and Schizophrenia; PSC, Pediatric Symptom Checklist; CPDS, Child Psychosocial Distress Screener; AUC, Area under the curve; Sens, Sensitivity; Spec, Specicity; PPV,
Positive Predictive Value; NPV, Negative Predictive Value
aoptimal cut-o determined through examining Receiver Operating Curve Tabs
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 10
Brown et al. International Journal of Mental Health Systems (2024) 18:21
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