Study setting and participants
This project was undertaken in partnership with an Aboriginal Community Controlled Health Organisation (ACCHO), which has a catchment area spanning approximately 640,000 km2, one of the largest covered by a single ACCHO in Queensland, Australia. Ethical clearance was granted by the Griffith University Human Research Ethics Committee (2022/362) and permission from the committee representing the local Traditional Owners of the Land was granted.
The focal participants were 84 children (60% male, 92% First Nations) who underwent a health check between 2019 and 2022, and had their development screened using both the RNDA:Australia and the BASC-3. Children were aged 3 to 16 years (M = 8.40, SD = 3.33). Of the participants where the administrator of the RNDA:Australia was documented, 87% were completed by healthcare workers who identify as First Nations, 5% by a general practitioner who identifies as First Nations, and 5% by a speech pathologist. Caregivers who answered questions for the RNDA:Australia and completed the BASC-3 attended the health check appointment with the child and were biological mothers (n = 40; 48%), other family members (i.e., siblings, grandparents, aunties/uncles; n = 26; 31%), or foster mothers (n = 9; 11%). Most children reported identifying with more than one Nation group, with 24% of participants identifying as Kalkadoon, 21% Waanyi, and 12% Waliwarra. All families were from a “very remote” region, as classified by the Modified Monash (MM) Model (MM 7 = very remote)21. During the data collection period, there were 90 children that had undergone a health check. However, one participant was excluded because they were younger than 24 months and had been screened using different RNDA:Australia items than all other participants. Another five participants were excluded due to missing scores on individual items on the RNDA:Australia, which were required for the analyses in this study.
Measures
The Behavior Assessment System for Children 3rd Edition (BASC-3).
For the current study, the BASC-3 Parent Rating Scale (PRS) was used as the reference measure. The BASC-3 was designed for assessing behavioural and emotional problems in children and adolescents and has three forms: preschool (2-5yrs), child (6-11yrs), and adolescent (12-21yrs). With an estimated administration time of 20 minutes, the BASC-3 has over 170 items that are descriptions of observable positive or negative behaviours. The caregiver responds to each item with Never (0 points), Sometimes (1 point), Often (2 points), or Almost always (3 points). Items are summed according to the scale to which they belong, yielding a raw score, which is then converted to a normative T score. Higher scores indicate more problems. The current study utilised gender-specific norms. T scores are computed for 4 content scales and 15 subscales, including hyperactivity, anxiety, and emotional self-control, as well as composite scores for externalising problems (hyperactivity + aggression + conduct problems) and a behavioural symptoms index (attention problems + atypicality + withdrawal). Table 1 outlines the 11 BASC-3 subscales that align with the RNDA:Australia behaviour domain items relevant to this study. The BASC-3 has been shown to have strong psychometric properties, with high internal consistency and test-retest reliability (α = ≥ .80) and excellent sensitivity (.95 − .97) and specificity (.79 − .80)22. Additionally, while the BASC-3 relies on a USA normative sample, Tan and colleagues23 found evidence to support its cross-cultural validity among Australian children.
To assess convergence, t-scores were used in correlational analyses. For calculations of sensitivity, specificity, total accuracy, positive predictive value, and negative predictive value, BASC-3 scores were dichotomized using a cut-off score of 1.5 standard deviations from the mean (1 = 65 or greater t-score, 2 = 65 or lower t-score). A cut off score of 1.5 standard deviations from the mean was selected as this is a common cut point for categorising children and adolescents at-risk for psychological and behavioural problems on a range of assessment instruments24.
RNDA:Australia
Due to normative developmental changes in children, the RNDA:Australia has 31 age-specific screening forms. Each form has screening questions for neurodevelopment across nine domains (gross & fine motor, vision, hearing, speech, cognition, behaviour, self-care & seizures). The current study examined the eight items within the behaviour domain, which are designed to be single-item measures of eight developmental and social-emotional problems. Some of these items were combined to create two additional subscales correspondent to the BASC-3 (i.e., externalising problems & behavioural symptoms index; see Table 1). Items are brief and draw attention to both strengths and weaknesses in social-emotional functioning. When reading the items to a caregiver, providers can flexibly adapt the wording of items according to the standards outlined in the manual.
Scores for each of the single-item measures within the behaviour domain are based on caregiver report to the healthcare provider (caregiver recall) and provider-observation during the assessment. For children under 5 years, individual items are scored as No concern (i.e., no impact on functioning; 0), Mild concern (i.e., minor limitations on functioning; 0.5), Moderate concern (i.e., mild to severe functional limitations; 1), or Severe concern (i.e., symptoms result in marked limitation in social, peer group, or occupational functioning and difficulty in management by family; 2). For children over 5 years, items are scored as No concern (1) or Impairment (2). There are some items relating to social-emotional problems that remain consistent across all age ranges (e.g., withdrawal, atypicality, attention problems), and some that emerge from age 5 (e.g., aggression, conduct problems). For correlational analyses to assess convergence, the nominal data was used. However, given the different scoring mechanisms across the age ranges, to run cross-tabulations for calculation of accuracy, scores for participants under 5 years were dichotomised and all scores were reverse coded where a score of 1 = Impairment and 2 = No impairment. Table 1 outlines how each of the relevant RNDA:Australia items align with subscales measuring corresponding constructs on the BASC-3.
Table 1
Alignment of RNDA:Australia behaviour domain items with constructs on the BASC-3
BASC Subscale | RNDA:Australia Item & Age |
Hyperactivity | • Hyperactive (5 + years) |
Aggression | • Acts very aggressively towards other people (5 + years) • Acts very aggressively towards other people (fights/bullies; 10 + years) |
Conduct problems | • Steals/lies/cheats (10 + years) |
Externalising problems | • Sum of items endorsed (hyperactive + aggression + conduct problems; correlational analysis) • Endorsement of 1 or more of the above (accuracy analyses) |
Attention problems | • Good attention to tasks (< 5 years) • Inattentive (5 + years) |
Atypicality | • No restricted, repetitive, stereotypic behaviour, interest and activity (< 5 years) • Shows odd/unusual behaviour (5 + years) |
Withdrawal | • Sociable (< 5 years) • Acts extremely withdrawn and shy (5 + years) |
Behavioural Symptoms Index (BSI) | • Sum of items endorsed (attention + atypicality + withdrawal; correlational analysis) • Endorsement of 1 or more of the above (accuracy analyses) |
Anxiety | • Extreme fear (5 + years) |
Emotional Self-control | • Temper tantrums (5 + years) |
Data collection tools and procedure
The health check comprised of several components, including: (1) demographic details; (2) cultural connections; (3) prenatal, developmental, educational, medical, and social history; (4) developmental screening utilising the RNDA:Australia; (5) clinical observations (vitals); (6) body systems review and physical examination (for detailed description of the health check see7). The Aboriginal Health Workers/Practitioners (AHW/Ps) completed components 1–5 and a general medical practitioner completed component 6. Where concerns were raised by a caregiver during the health check or flagged by the RNDA:Australia, the AHW/Ps administered the BASC-3 at a follow-up session with the caregiver, which was then entered and scored digitally using a secure cloud-based scoring system. Families where no concerns were raised during the health check, but who agreed to be contacted for future research, were contacted by phone and asked to complete the BASC-3 over the phone with a university research assistant. Data were entered into a REDCap database25 developed in partnership with the ACCHO staff members. Health providers were blind to the purpose of this study. Only relevant demographic data, RNDA:Australia scores, and BASC-3 scores were used in the current study. Participants who had completed multiple health checks between 2019 and 2022 were only included in the study once, with the RNDA:Australia and BASC-3 data administered closest in time selected for inclusion.
Statistical Analyses
Point-biserial correlations (rpb) were used to draw conclusions about the concurrent validity (convergence) of the RNDA:Australia screening scores (nominal data) compared to the BASC-3 subscale scores (t-scores). Cross-tabulation of dichotomous indicators derived from the RNDA:Australia and BASC-3 results was used to produce the sensitivity, specificity, PPV, NPV, prevalence, and total accuracy of the RNDA:Australia with the BASC-3 used as the reference measure.