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A VALIDITY AND RELIABILITY STUDY OF


ASSESSMENT AND SCREENING FOR SUSTAINED
WITHDRAWAL REACTION IN INFANCY: THE
ALARM DISTRESS BABY SCALE
ANTOINE GUEDENEY

Department of Child and Adolescent Psychiatry, Hopital Bichat-Claude Bernard


JACQUES FERMANIAN

Department of Biostatistics, Hopital Necker-Enfants Malades

ABSTRACT: Sustained withdrawal behavior in infancy is an important alarm signal to draw attention to
both organic and relationship disorders. A withdrawal scale, the Alarm Distress Baby scale (ADBB), for
infants between 2 and 24 months of age was built. This article describes the construction of the scale and
the assessment of its psychometric properties. The ADBB has good content validity, based on the advice
of seven experts. The scale has good criterion validity: rst, as a measure of the infants withdrawal
reaction, with a very good correlation between nurse and pediatrician on the ADBB (rs 0.84), and
second, as a screening procedure for detecting the developmental risk of the infant. The cutoff score of
5 with a sensitivity of 0.82 and a specicity of 0.78 was determined to be optimal for screening purposes.
The scale has good construct validity, with good convergent validity with both the Spitz (1951) and the
Herzog & Rathbun (1982) lists of symptoms of infant depression (rs 0.61 and 0.60, respectively).
Exploratory factor analysis showed two different factors, consistent with the scales construct. Reliability
was satisfactory with good internal consistency for both subscales (the Cronbach 0.80 for the rst
subscale and 0.79 for the second) and for the global scale ( 0.83). The test-retest procedure showed
good stability over time (rs 0.90 and 0.84 for the two different raters). The scale could be used in
different clinical settings, provided a sufcient level of social stimulation is given to the infant in a

This study would not have been possible without the support of Marcelle Delour, M.D., Head of medical services,
Protection Maternelle et Infantile de Paris. Janine Charon, M.D. (Head of PMI, 14th district of Paris), Francois Roge,
M.D., pediatrician (PMI, IPP), Malika Benjellal-Zamoun, puericultrice de jeunes enfants (PMI, IPP), Annie GauvainPiquard, M.D. (IGR, Villejuif), Martine Vermillard, nurse (PMI, IPP), Caroline Dumont (psychologist), Heloise Courtier (psychologist), and Edith Thoueille, director (PMI, IPP) have directly participated in the study. Rachael Henry,
Ph.D. (Wollongong, Australia), R. Kumar, Ph.D. M.D. (Maudsley, London), and Campbell Paul, M.D. (Royal Childrens Hospital, Melbourne) have kindly provided expert advice at different points of the study. Frederic Atger, M.D.
(Institut Mutualiste Monsouris, Paris) has been very helpful in the use of the statistical software. Annie Nataf-Cooper
Rusconi, M.D., Marianne Kumar, Gise`le Danon, M.D., and Denise Parise made translations and back-translations of
the scale from French to English. Kaija Purra, M.D. (Tampere University, Finland), Priti Patel, M.D., Dilys Daws
(Tavistock Clinic, London), and Stephen Matthey (South Western Sydney Area Health Service, Australia) have kindly
provided editing help. The study has beneted from the nancial help of the Nestle Corporation. Direct correspondence
to: Dr. Antoine Guedeney, Hopital Bichat-Claude Bernard, policlinique Ney, 124 blvd Ney, 75018 Paris, France; email: guedeney@bch.ap-hop-paris.fr.
INFANT MENTAL HEALTH JOURNAL, Vol. 22(5), 559 575 (2001)
2001 Michigan Association for Infant Mental Health

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relatively brief period of time. The scale can be used by nurses and psychologists or by medical doctors
after a short period of training.

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RESUMEN: Cuando la conducta de ensimismarse o apartarse es sostenida durante la infancia nos encon-

tramos frente a una importante senal de alarma que nos hace dirigir la atencion hacia los trastornos
organicos y los que se presentan dentro de una relacion. Se ha establecido una escala para determinar el
ensimismamiento en infantes entre los 2 y 24 meses de edad, la cual se denomina Alarm Distress Baby
scale (ADBB). Este ensayo describe la estructuracion de dicha escala y la evaluacion de sus propiedades
sicometricas. La ADBB tiene una muy buena validez de contenido, basandose en el consejo de siete
expertos. La escala tambien posee una validez en cuanto al buen criterio: primero como una forma de
medir la reaccion de ensimismamiento del infante, con una buena correlacion entre enfermera y pediatra
en la ADBB (rs 0.84); y segundo, como un procedimiento investigativo para detectar el riesgo de
desarrollo del infante. Se determino que un puntaje maximo de 5, con una sensibilidad de 0.82, y una
especidad de 0.78, era el puntaje optimo para los propositos investigativos. La escala tiene asmismo
una buena validez de estructuracion, con buena validez convergente con referencia a las listas de sntomas
de la depresion infantil de Spitz (1951) y de Herzog & Rathbun (1982) (rs: 0.61 y 0.60). El analisis del
factor de exploracion mostro dos diferentes factores, consistentes con la estructuracion de la escala. La
abilidad es satisfactoria con buena consistencia interna tanto para las sub-escalas (alpha de Cronbach
0.80 para la primera sub-escala y 0.79 para la segunda) como para la escala global (alpha 0.83). El
procedimiento de examinacion y re-examinacion mostro buena estabilidad con el pasar del tiempo (rs
0.90 y 0.84 para los dos sistemas de evaluacion). Esta escala pudiera ser usada en diferentes escenarios
clnicos, siempre y cuando que se provea un nivel suciente de estmulo hacia el infante en un perodo
de tiempo relativamente breve. La escala puede ser usada por las enfermeras y los sicologos as como
tambien por los medicos, despues de un perodo corto de entrenamiento.
RESUME: Un comportement prolonge de repli et retrait est un signal dalarme important attirant lattention

sur a` la fois des troubles organiques et des troubles relationnels. Une echelle de retrait et repli (echelle
dalarme pour le desarroi chez le bebe, abrege ADBB en anglais) pour les nourissons entre 2 et 24 mois
a ete construite. Cet article decrit la construction de lechelle et levaluation de ses proprietes psychometriques. L ADBB a une bonne validite de teneur, basee sur les conseils de sept experts. Lechelle a une
bonne validite de crite`re: dabord en tant que mesure de la reaction de repli et retrait du nourrisson, avec
une tre`s bonne correlation entre le pediatre et linrmie`re sur la ADBB (rs0,84); et deuxie`mement en
tant que procedure de depistage du risque dans le developpement du nourrisson. La limite placee a` 5 avec
une sensibilite de 0,82 et une specicite de 0,78 fut determinee an detre optimale pour le depistage.
Lechelle a un bonne validite conceptuelle, avec une bonne validite de convergence avec les listes de
symptomes de depression du nourrisson de Spitz (1951) et Herzog et Rathbun (1982) (rs: 0,61 et 0,60).
Les analyses exploratoires de facteur ont montre deux facteurs differents, correspondant a` la conceptualisation de lechelle. La abilite est satisfaisante avec une bonne coherence interne pour a` la fois les
sous-echelles (lalpha de Cronbach 0,80 pour la premie`re sous-echelle et 0,79 pour la seconde) et pour
lechelle globale (alpha0,83). La procedure de test-retest a montre une bonne stabilite au l du temps
(rs0,90 et 0,84 pour deux evaluateurs differents). Lechelle pourrait etre utilisee dans des contextes
cliniques differents, a` condition quun niveau sufsant de stimulation sociale soit donnee au nourrisson
dans un periode relativement bre`ve. Lechelle peut etre utilisee par les inrmie`res et les psychologues ou
par les docteurs, apre`s un courte periode de formation.

ZUSAMMENFASSUNG: Ein dauernder Ruckzug von Kleinkindern ist ein wichtiges Alarmsignal sowohl bei
organischen Krankheiten, als auch bei Beziehungsstorungen. Eine Bewertungsskala fur Ruckzug von
Kleinkindern (Alarm: Unwohlsein bei Babys Bewertungsskala: ADBB) zwischen 2 und 24 Monaten
wurde erstellt. Diese Arbeit beschreibt den Aufbau und die Messung der psychometrischen Moglichkeiten
der Skala. Nach der Meinung von sieben Experten hat der ADBB eine gute Inhaltsvaliditat. Die Skala hat
eine gute Konstruktvaliditat: Zuerst als Meinstrument der Ruckzugsreaktion des Kleinkinds, mit einer

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sehr guten Korrelation zwischen der Krankenschwester und dem Kinderarzt im ADBB (rs 0.84);
zweitens eine Reihenuntersuchung, um Entwicklungsrisiken bei Kleinkindern zu entdecken. Der Grenzwert von 5, mit einer Sensitivitat von 0.82 und einer Spezitat von 0.78 wurde fur die optimale Reihenuntersuchung festgestellt. Der Fragebogen hat eine gute Konstruktvaliditat, mit einer guten konvergenten
Validitat, sowohl mit der Liste der Symptome der kleinkindlichen Depression nach Spitz (1951) und
Herzog & Rathburn (1982) (rs: 0.61 und 0.60). Bei der Exploration zeigten sich zwei Faktoren, die
passend zur Konstruktion des Fragebogens positiv geladen waren. Die Reliabilitat ist zufriedenstellend
mit einer guten inneren Konsistenz fur beide Subskalen (Cronbachs alpha 0. 80 fur die erste Subskala
und 0.79 fur die zweite) und fur die globalen Skalen (alpha 0.83). Das TestRestest Verfahren zeigte
eine gute Stabilitat uber die Zeitachse (rs 0.90 und 0.84 fur zwei verschiedene Untersucher). Der
Fragebogen kann in unterschiedlichen klinischen Anwendungen verwendet werden, vorausgesetzt, das
eine entsprechende Stimulation des Kleinkinds in einer relativ kurzen Zeit sichergestellt werden kann.
rzten nach einer kurzen Trainingszeit
Der Fragebogen kann von Krankenschwestern, Psychologen und A
verwendet werden.

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The concept of withdrawal in infants remains somewhat underdened, despite its frequent
uses in clinical practice and in the process of clinical evaluation (Guedeney & Lebovici, 1997).
Brief withdrawal is a normal mechanism in the mother-infant interaction when observed at a
microanalytic level with nonclinical populations (Brazelton, Klosowski & Main, 1974; Weinberg & Tronick, 1994; Beebe, Lachmann & Jaffe, 1997). On macroscopic and clinical levels,
sustained infant withdrawal is observed in several clinical situations, apart from the well-known
organic causes, such as fever, dehydration, postcritical state after seizure, intoxication, diseases
of the central nervous system, or visual and auditory sensory impairment (Behrman, Vaughan
& Nelson, 1983).

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The most salient causes of withdrawal in infancy are autism and Pervasive Developmental
Disorders, where withdrawal is constant and is a key element of the diagnosis, no matter which
classication system is used. Withdrawal is a key symptom of infant depression (Spitz, 1946,
1951; Herzog & Rathbun, 1982; Guedeney, 1997, 2000). Withdrawal behavior has a strong
correlation with insecure attachment (Rubin & Lollis, 1988; Ward, Kessler & Altmann,
1993). Withdrawal is a feature of most attachment disorders (Zeanah, Boris, Baskshi & Lieberman, 2000). Fraiberg (1982) described the freezing reaction, observed among infants
when they are faced with very adverse conditions. Recently, infant withdrawal has been recognized as an element of the clinical picture of attachment disorganization (Solomon & George,
1999).
In severe forms of protein-deciency malnutrition, such as Kwashiorkor, withdrawal is
intense and prolonged, and its abatement is a reliable sign of recovery (Guedeney, 1987, 1995,
1997). Withdrawal is also a key feature of nonorganic failure to thrive (Powell & Low, 1983;
Powell & Bettes, 1992). Menahem (1984) described two infants with possible conservationwithdrawal reaction arising from grossly inadequate feeding and suggested that many infants
with nonorganic failure to thrive (NOFTT) can be understood better within the context of
conservation-withdrawal. Engel and Schmale (1972) developed the concept of ConservationWithdrawal as a biological threshold mechanism where survival of the organism is supported
by process of disengagement and inactivity, vis-a-vis the external environment (p.75). Engel
& Reichsman (1956, 1979) described the case of Monica, who presented with a severe state
of withdrawal during a long hospitalization, and they followed her for 25 years.
Infant withdrawal is a key element of the infants response in the face of of a noncontingent
kind of relationship. This can be observed in the still-face experiment (Cohn & Tronick,1983;
Field, 1984; Seifer & Dickstein, 1993; Tronick & Weinberg, 1997), in studies of the effect of
maternal depression (Murray & Cooper, 1997), or in parents who have other kinds of mental
impairment (Reder & Lucey, 1995). Severe withdrawal can be observed also at different levels
in infants with Anxiety Disorders, Post Traumatic Stress Disorders (Zeanah, 1993), and in
children who have suffered from chronic and severe pain in infancy (Gauvain-Piquard, Rodary,
Rezvani & Lemerle, 1987; Gauvain-Piquard, Rezvani, Rodary & Serbouti, 1999).
Although withdrawal is a very important alarm signal (Ironside, 1975), no assessment tool
is available to date, to our knowledge. This article describes the construction and the validation
of a scale, the Alarm Distress Baby Scale (ADBB), designed to assess sustained withdrawal
reactions in infants aged between 2 24 months.

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METHOD
Subjects

Inclusion criteria. All infants male or female, aged 2 24 months, of any national or ethnic
background, seen for an initial follow-up visit at the Well-Baby Clinic (PMI) by F. Roge,
pediatrician, and by M. Vermillard, infant nurse, at the Institut de Puericulture de Paris between
July 1996 and July 1997 were eligible for the study. Only new patients were eligible, so that
both the pediatrician and the nurse would not be inuenced by any previous knowledge of the
familial and medical backgrounds of the child. The upper age limit of 24 months was picked
to demonstrate that sustained withdrawal reaction could be assessed during a period of rapid
and dramatic developmental growth and before the use of language. The lower age limit of 2
months was chosen after reviewing the literature (Cioni et al.,1977; Prechtl et al., 1997), taking
into account the duration of the fetal period and its inuence after birth.

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Exclusion criteria. We excluded subjects from the study as follows:

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1. Infants with any acute disease that could be in itself responsible for a state of withdrawal
or prostration, such as fever (above 37.5 C or 99.5 F), dehydration, recent seizures,
intoxication, acute otitis media, or any cause of severe acute or chronic pain;
2. Infants with acute and chronic neurological problems, and infants with known visual
or auditory impairment;
3. Premature and small for date babies ( 37 weeks gestational age, and infants whose
birth weight was below the third standard deviation [SD] on growth charts); and
4. Infants already followed at the PMI.
Procedure. The consultation was videotaped with a VHS camera, which focused only on the
infant. Written informed consent was required from the parents just before the consultation.
All infants with clear withdrawal behavior were followed by the PMI team, and were referred,
if necessary, to our nearby infant guidance clinic for evaluation and treatment. The research
protocol was approved by the Ethics Committee (Faculte de Medecine Necker-Enfants Malades, Paris).
Instrument Construction

The main idea in designing the scale was to build an instrument simple enough to be used
effectively by nurses in clinical practice. The medical consultation is used in the same way as
the Winnicott set situation (Winnicott, 1941), which provides a given stimulation and observes the way the infant makes uses of it. .
The scale was built in three steps. The 14-items scale by Powell & Low (1983) was taken
as a starting point. Their study dening behavior that differentiated between organic and nonorganic failure to thrive (FTT) showed that abnormal interpersonal behaviors were more
common than non-interpersonal behaviors in hospitalized infants with nonorganic failure to
thrive. The Powell & Low eight noninterpersonal items were as follows: general inactivity,
excessive crying and irritability, exed hips and knees, expressionless face, infantile posturing,
rumination, excessive thumb sucking, and disproportionate hand and nger inactivity. Their
six interpersonal items were as follows: crying when approached, lack of decreased vocalization, lack of cuddliness, poor eye contact, lack of response, and indifference to separation.
However, the Powell & Low study was made with only 21 hospitalized infants, with no validity
or reliability studies, and some of the items in their scale (for example infantile posturing, or
exed hips and knee) were observed with only severely distressed infants. Therefore, a rst
draft of the ADBB was made with only 10 items that corresponded more appropriately with
the interpersonal and non interpersonal dimensions of the withdrawal behavior: facial expression, eye contact, general activity, self-stimulating gestures, vocalizations, response to stimulation, relationship to observer, ability to attract attention, reaction to cuddling, and reaction to
separation. After the items were examined for content validity by four experts (A. GauvainPiquard, S. Lebovici, M. Soule, D. Widlocher), two items, reaction to cuddling; and reaction
to separation, were removed. The 8-item version of the scale then was tested on 29 infants
who had very different kinds of clinical conditions. Taking into account the difculties encountered during these initial assessments, we modied the scale following the advice of ve
experts (R. Brunod, R. N. Emde, H. Fitzgerald, M. Soul, Ch. H. Zeanah) to clarify the item
descriptions.
This provisional scale was tested on 40 infants, each of whom was rated simultaneously

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by a pediatrician, a nurse, and Antoine Guedeney, the rst author of this article. The distribution
of the total scores were examined, various factor analyses were performed, and interrater reliability was assessed by using statistical methods described below. Taking into account the
results of these analyses, we made improvements in the formulation of some of the items,
which lead to the present and nal version of the scale (see appendix). The nal version of the
scale was translated into English (Annie Nataf-Cooper, M.D.), then blindly retranslated into
French (Marianne Kumar).

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Assessment of Psychometric Properties

The psychometric properties of the French version of the scale were assessed in the following
manner (American Psychological Association, 1985):
Validity
Face validity. The meaning and acceptability of the items were investigated by the raters
during the administration of the questionnaire.
Content validity. Seven experts on infant psychopathology, infant depression, and affect
disorders in infancy who had experience in designing and validating assessment scales (R.
Brunod, R. N. Emde, A. Gauvain-Piquard, S. Lebovici, M. Soule, D. Widlocher, Ch. H.
Zeanah) checked independently if the items of the scale did correspond with the two hypothesized interpersonal and noninterpersonal dimensions of the withdrawal reaction.
Criterion-related validity. Criterion-related validity was investigated in two ways.
First, the ADBB was used as a measure of the intensity of the withdrawal reaction. Each
of the infants was rated simultaneously by the rst author (A.G.), considered an expert, using
a visual analog scale (VAS), by the pediatric nurse of the PMI, and by one of the consulting
pediatrician of the PMI, who both used the ADBB. The expert, the pediatrician, and the nurse
lled out the scales independently and simultaneously immediately after each medical examination. Considered the gold standard, the VAS ranged from 0 (absence of withdrawal) to 100
(severe withdrawal). The correlation coefcients between the experts VAS scores and, respectively, the nurses scores and the pediatricians scores assessed the concurrent validity of
the ADBB.
Second, the ADBB was used as a screening tool, through the evaluation of its sensitivity
and specicity, for detecting the developmental risk for the infant in the following year (predictive validity). The developmental tests available and validated on the French population
have no predictive value for development (Josse, 1979). The developmental risk was, therefore,
rated high or low by the rst author on the basis of the 17 items (see Appendix A), which were
systematically collected for each infant by the PMI team (nurse, pediatrician, head nurse) since
its participation in an epidemiological study in 1982 that aimed to determine the developmental
risk factors in infancy (Choquet, Facy, Laurent & Davidson, 1982). In their study, a sample of
415 infants representative of the 14 districts of Paris was followed for 3 years. Four questionnaires describing childrens health and behavior were completed at 3, 9, 18, and 36 months.
First, a cluster analysis was carried out on the collected variables, and three different groups
of children were identied (high, middle, and low risk). Ten percent (10) of the children
belonged in the high risk group and were characterized by 6 of the 17 items listed in Appendix
A. Second, a follow-up study showed that these criteria were reliable in discriminating between
risk infants and others (Choquet & Ledoux, 1985).
In our study, we considered only two categories of infants, those classied as high risk if
they had, as in the preceding study, 6 or more of the 17 items listed Appendix A and those
classied as low-risk group if they had 5 or less of these 17 items.

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In this study, sensitivity is, thus, dened as the proportion of infants classied as withdrawn
by the ADBB (score equal or above a cutoff point) from the total number of infants classied
as having a high developmental risk. Specicity is dened as the proportion of infants classied
as not withdrawn by the ADBB (score below the xed cutoff point) from the total number of
infants classied as having a low developmental risk. The nurses total scores with the ADBB
on live examinations were used to evaluate sensitivity and specicity.
Construct validity. There were several components to construct validity:

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1. Convergent validity was assessed by the correlation coefcients between the nurses
total scores with the ADBB and each of the two variables relating to withdrawal and
representing the severity of the state of depression in the infant. The rst variable was
the number of pathologic events during the year after the assessment with the ADBB
and belonging to the list of symptoms given by Spitz (1951) in his description of
anaclitic depression. The second variable was the number of pathologic events, calculated as above, listed in the Herzog & Rathbun (1982) description of infant depression.
Table 1 shows the list of symptoms or behaviors present in each description. After
carefully checking with the pediatrician, we included in the calculation of the variables
each pathologic event reported in the PMI medical record of the infant.
2. Discriminant validity was assessed through the correlation coefcient between the
nurses ADBB total scores and several variables thought to have no relationship with
withdrawal: age of the mother, parity, age of the father, age of the infant, birth rank,
and duration of the well-baby clinic consultation.
3. Exploratory factor analysis was made in order to investigate the internal structure of
the scale, as described in the statistical methods section.

Reliability. This was tested in three ways.


1. The interrater reliability between the nurse and the pediatrician was calculated on the
basis of their live assessments, made immediately after each consultation and without
discussing it (see criterion-related validity).
2. Two psychology students (H. Courtier and C. Dumond) were trained in the use of the
ADBB, through live examinations at PMI and through videotaped sessions, using the
documents recorded during the pilot study described above. Then, they scored blindly
TABLE 1. Spitz and Herzog & Rathbuns Lists of Symptoms of Infant Depression

Spitzs Criteria for Anaclitic Depression

Herzog & Rathbun Developmentally Specic


Criteria for Infant Depression (036 months)

Increased demandingness
Weepiness
Loss of weight
Arrest of developmental progress
Insomnia
Rigid facial expression
Restriction of mobility
Withdrawal

Failure to thrive or rumination


Lack of social play
Persistent lethargy or irritability
Separation or attachment problems
Agitation, aggression
Developmental delays
Sleep disorders
Feeding difculties

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and independently the whole set of 60 videotapes of the present study, in random order,
in order to measure their interrater reliability on the videotaped documents.
Six months later, the two psychology students did the same assessment again,
independently, and again in random order, to provide an evaluation of the test-retest
reliability with videotaped documents. The interrater and test-retest reliabilities were
assessed using the intraclass correlation coefcient as described below.

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3. The internal consistency was assessed rst by using the Cronbach coefcient (Cronbach, 1951), considering the ADBB as a global scale. Taking the results of the factor
analysis into account, the assessment of the internal consistency then was made separately for each of the two subscales (see below).

Statistical methods. The quantitative variables were described using means, standard deviations [SD], and ranges. Qualitative variables were described using frequencies and percentages.
The relationship between two quantitative variables was assessed using the Spearman correlation coefcient [rs ] because the binormality of the sampled distribution could not be assumed.
It was tested if each correlation coefcient differed signicantly from zero. As expected, correlation coefcients assessing criterion and convergent validity were highly signicant, whereas
all those measuring discriminant validity were nonsignicant. To simplify the presentation of
the results, we did not report the p values of the previous tests in the text. The interrater and
the test-retest reliability were assessed using the intraclass correlation coefcient [ICC] under
the random-effect model. After we estimated the components of total variance by analysis of
variance, we calculated the ICC in the usual manner (Shrout & Fleiss, 1979). Factor analysis
of the scale was performed using the principal component analysis as the method of extraction.
The Cattell screen test was used for determining the number of factors extracted. Independent
factors were obtained using the Varimax rotation method. All the statistical tests were twotailed, and their level of signicance was 0.05. Statview II (SAS Institute) was the
statistical software used.
RESULTS
Description of Subjects

One family out of 61 refused to take part in the study because the person accompanying the
child was not a parent. Sixty infants were nally included. The mean age of infants was 30.5
weeks, [SD: 21.51 wks; range: 8 96 wks]. The mean age of mothers was 30.1 years [SD: 5.68
yrs; range: 20 44 yrs]. Mean age of fathers was 35.2 years [SD: 9.96 yrs; range: 23 67 yrs].
Following criteria listed in Appendix A (see above), the proportion of high developmental risk
infants was 11 out of 60 (18.3). The sociodemographic and obstetric characteristics are
summarized Table 2. Socioeconomic status (SES) was assessed following French Parisian
Inserm criteria (Inserm, 1975). Nurses total ADBB score had a mean value of 3.4 [SD: 3.78;
range: 0 17]. Figure 1 shows the distribution of the nurses total scores.
Psychometric Properties of the ADBB

Validity
Face validity. All items of the scale were judged acceptable, easy to understand, and
easy to ll out by the raters, the nurses, the pediatrician, and the psychology students.

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TABLE 2. Sociodemographic and Obstetric Characteristics of the Studied Subjects (N 60)


Variables

Sex

Socioeconomic status (SES)

Geographic origin of the mother

Geographic origin of the father

Parity

Rank of birth

Girls
Boys

28
32

46.66
53.33

Very high
High
Middle
Low
Very low

3
8
24
19
6

5.00
13.33
40.00
31.66
10.00

French metropolitan
French overseas departments
North Africa
Africa
Asia
Other

35
2
7
6
5
5

58.33
3.33
11.66
10.00
8.33
8.33

French metropolitan
French overseas departments
North Africa
Africa
Asia
Other

32
1
9
8
7
3

53.33
1.66
15.00
13.34
11.67
5.00

1 child
2 children
3 children
3 children

32
17
5
6

53.33
28.34
8.33
10

First born
Second
Third or later

49
7
4

81.67
11.66
6.67

FIGURE 1. Distribution of the nurses ADBB total scores.

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TABLE 3. Specicity and Sensitivity of the ADBB


for Different Cutoff Scores
Cutoff
scores

Sensitivity
Specicity

0.82
0.78

0.64
0.80

0.55
0.86

0.45
0.96

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Content validity. The seven experts independently judged that each item corresponded
to a postulated dimension and that each dimension was represented by several items. Considering that the main characteristics of the universe of items were reproduced in the proper
proportions and balance, the experts concluded independently that the content validity was
good.
Criterion validity. Criterion validity was investigated in two situations. First (concurrent
validity) as a measure of the severity of the infants withdrawal reaction, the experts VAS
scores were well correlated with the nurses scores on the ADBB [rs 0.67] and with the
pediatricians score [rs 0.63], respectively.
Second (predictive validity), the ADBB was used as a screening procedure for detecting
the developmental risk of the infant in the year after the assessment. The sensitivity and specicity of the scale for different cutoff scores are displayed Table 3.
The cutoff score of 5 with a sensitivity of 0.82 and a specicity of 0.78 was determined to be
optimal for screening purposes.
Construct validity. We tested three measures of construct validity.
1. Convergent validity. The correlation coefcients between the nurses score with the
ADBB and the number of pathologic events, different or not, during the year after the
assessment were calculated separately with the two available descriptions of infant
depression and are, respectively, rs 0.61 for Spitz anaclitic depression (1951) and
rs 0.60 for Herzog & Rathbun (1982) criteria.
2. Discriminant validity. As expected, no signicant correlation was found between the
total score on the ADBB by the nurse and the age of the mother [rs 0.048], parity
[rs 0.175], age of the father [rs 0.020], age of the infant [rs 0.225], rank of birth
[rs 0.175], or duration of the consultation [rs 0.212].
3. Factor analysis extracted two orthogonal factors which accounted for 63.3 of the
variance. The factor loading for each item is shown in Table 4. The rst factor (FI) has
5 items: 2 (eye contact), 3 (general level of activity), 4 (self-stimulating gestures), 7
(relationship), and 8 (attractivity). The second factor (FII) has 3 items: 1 (facial expression), 5 (vocalization), and 6 (response to stimulation). The loading of item 6
(response to stimulation) was close for FI and FII; however, this item was classied as
FII, after we took into account its clinical meaning (Harman, 1967).

Reliability
1. The interrater reliability between the nurse and the pediatrician during the live assessments of the 60 infants with the ADBB was very good (ICC 0.84).

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TABLE 4. Results of Factor Analysis; Loading 5 0.50 Are


Not Reported

Eigenvalues
Percentage of total variance explained
Factor loading
item 1
item 2
item 3
item 4
item 5
item 6
item 7
item 8

Factor 1

Factor 2

3.882
48.5

1.201
15.1

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.841
.750
.566
.538
.532
.774
.761

.902
.657

2. The interrater reliability between the two psychology students on the 60 videotaped
examinations was also good for both the rst assessment (ICC 0.88) and for the
second assessment, performed 6 months later (ICC 0.87). The ICC coefcients that
assessed the test-retest reliability on videotaped documents were, respectively, 0.90 for
the rst psychology student and 0.84 for the second.
3. When the ADBB is considered as a global scale, the internal consistency assessed by
the Cronbach is 0.83. When we took into account the two-factor structure of the
ADBB, the Cronbach was 0.80 for the rst subscale and 0.79 for the second subscale.

DISCUSSION
Psychometric Properties

Validity
Face and content validity
1. During this validation study, all the users of the ADBB, especially nurses and psychology students, found that the scale had good face validity and was easy to ll out
in a short period of time (5 minutes maximum). This was conrmed during all the
training sessions performed later, after the completion of the present study.
2. The seven experts who assessed the content validity were all experienced clinicians
specializing in various elds of infant psychopathology, such as depression, pain, or
attachment regulatory disorders or post traumatic stress disorders. Their independent
judgements were all in close agreement and resulted in a good content validity.

Criterion validity. Because of his clinical experience with infants who exhibited withdrawal
behavior (Guedeney, 1987, 1995, 1997, 2000), A. Guedeney was considered an expert. His
assessments of the severity of the withdrawal through the use of a VAS and his judgement on
the further developmental risk for the infant were considered as references for calculating

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concurrent and predictive validity. We found these two types of criterion validity satisfactory.
This suggests that the ADBB can easily be used in clinical practice, especially by nonmedical
users, both for assessing the intensity of withdrawal and for detecting with good sensibility
and specicity the developmental risk of the withdrawn infant.
Construct validity

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1. Convergent validity
Several authors have pointed out that withdrawal behavior is related to infant depression
(Spitz, 1946, 1951; Herzog & Rathbun, 1982; Powell & Bettes, 1992). Although it is
commonly used in clinical practice, the concept of infant depression rarely is dened
accurately. Only Spitz (1946, 1951) and Herzog & Rathbun (1982) have, to our knowledge, published a list of symptoms of depression in infants. Using each of the two lists
of symptoms of infant depression, we calculated the number of pathologic events in
the year after the assessment with the ADBB. Each event, notable enough to be reported
in the PMI medical le, was considered pathologic after we carefully checked with
the pediatrician in charge of the infant. We, therefore, obtained an objective and valid
measure of the severity of the state of depression of the child and responded with the
usual clinical approach. We found that withdrawal behavior was related to depression
as dened by each list (rs 0.61 and rs 0.60, for the Spitz and Herzog & Rathbun
lists of symptoms, respectively). However, this also indicates that the ADBB scale is
not identical to a depression scale.
2. Factor analysis
The observed internal structure of the scale with ve items loading on FI (interpersonal
dimension) and three items loading on FII (noninterpersonal dimension) is consistent
with the two-factor structure of the construct underlying the construction of the scale
(see Methods). This structure should, however, be conrmed by further studies with a
greater number of infants.
Taking into account both the results of the factor analysis and the good convergent and
discriminant validity, we consider that the construct validity is satisfactory (Coste, Fermanian
& Venot, 1995).
Reliability. The good interrater reliability has been achieved with in-person and videotaped
training. Moreover, the good ICC coefcient. (0.84) between the nurse and pediatrician shows
that the scale is effective in enabling the pediatrician and the nurse to have a closer appreciation
of the withdrawal behavior of the infant. The test-retest coefcients show good stability of
rating over time. When the ADBB is considered as a global scale, the internal consistency
assessed by the Cronbach (0.831) demonstrates that the items are interrelated well. When
the two-factor model is retained, the values of the Cronbach for each subscale (0.80 for FI,
0.79 for FII) show that each has good internal consistency without too much redundancy of
the items.
In conclusion, this eight-items scale has good content and criterion validity. Its construct
validity is satisfactory. The interrater and test-retest reliability is very good, both for live and
on video assessments. The ADBB can be used for measuring the severity of withdrawal
behavior or as a screening tool for detecting further developmental risk with the withdrawn infant. After a short period of training, a medical doctor or nonmedical professionals,
especially nurses or psychologists, can perform the assessment.The scale should facilitate the
recognition and the evaluation of withdrawal behavior in infants who are seen in common
clinical practice.

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APPENDIX A

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Criteria used to determine infants with high developmental risk (Choquet, Facy, Laurent, &
Davidson, 1982). At least 6 out of 17 are needed for a child to belong in the high risk developmental group.

-Wakes up frequently at night


-Disturbed sleep pattern
-Often angry
-Often dissatised
-Receives sedative drugs
-Hospitalized for more than 3 days between the age of 18 months and 3 years
-Poor healthaccording to the mother
-Has asthma
-Several accidents between 18 months and 3 years of age
-Has nightmares
-Erratic appetite
-Frequent rhinitis
-Going to bed and getting asleep is difcult
-Frequent bronchitis
-Frequent otitis media
-No thumb sucking, or substitute
-Does not play alone

APPENDIX B

Alarm Distress BaBy Scale (ADBB)


Assessment of withdrawal behavior in infancy
Each item is rated on a scale from 0 to 4:
0: No unusual behavior
1:
2:
3:
4:

Doubt as to unusual behavior


Mild unusual behavior
Clear unusual behavior
Severe unusual behavior

This scale is best rated by the observer on the basis of her/his observations, immediately
following the clinical interview. Initially, spontaneous behavior is assessed, then following
stimulation (smile, voice, gesture, touch, etc.), and the evolution along time. The rating is what
seems more signicant during the whole examination procedure. In case of doubt between two
ratings return to the denition above.
1. FACIAL EXPRESSION: Observer assesses any reduction of facial expressiveness:
0: Face is spontaneously mobile, expressive, animated.
1: Face is mobile, expressive, but limited in range.
2: Little spontaneous facial mobility is exhibited.
3: Face is xed, sad.
4: Face is xed, frozen, absent, appearing prematurely old.

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2. EYE CONTACT: Observer assesses the reduction of eye contact:


0: Eye contact is spontaneous, easy and sustained.
1: Eye contact is brief and spontaneous.
2: Eye contact is possible only when initiated by observer.
3: Eye contact is eeting, vague, elusive.
4: Eye contact is totally avoided.

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3. GENERAL LEVEL OF ACTIVITY: Observer assesses any failure of motion of the


head, torso, and limb without taking into account hands and ngers activity:
0: Frequent and well coordinated, spontaneous head, torso and limb motions.
1: Reduced general level of activity, few head and limb movements.
2: No spontaneous activity, but reasonable level in response to stimulation.
3: Low level of activity in response to stimulation.
4: Immobile, rigid, stiff, whatever the stimulation.
4. SELF-STIMULATING GESTURES: Observer assesses the frequency with which the
child plays with his/her own body: ngers, hand, hair, thumb sucking, repetitive rubbing
etc., in relation to the general level of activity. One signicant sign of self-stimulating
gesture is sufcient to rate a 1 or higher.
0: Absence of self-stimulation; autoexploration is appropriate to the level of general
activity.
1: Self-stimulation occurs eetingly.
2: Self-stimulation is rare but obvious.
3: Self-stimulation is frequent.
4: Self-stimulation is constant.
5. VOCALIZATIONS: Observer assesses the lack of vocalization expressing pleasure
(cooing, laughing, babbling, babbling with consonant sounds, squealing with pleasure),
but also lack of vocalization expressing displeasure or pain (screaming or crying):
0: Frequent, cheerful, modulated spontaneous vocalizations; brief crying or screaming
in response to an unpleasant stimulation or sensation.
1: Brief spontaneous vocalizations, frequent screaming or crying (even if only in response to stimulation).
2: Constant crying.
3: Whimpering only in response to stimulation.
4: Absence of vocalization.
6. BRISKNESS OF RESPONSE TO STIMULATION: Observer assesses the sluggishness of response to pleasant or unpleasant stimulation during the examination (smile,
voice, touch). The amount of response is not being assessed here, but the delay in
response.
0: Appropriate, brisk and swift response to stimulation.
1: Slightly delayed and sluggish response to stimulation.
2: Sluggish, delayed response to stimulation.
3: Markedly sluggish response to even unpleasant stimulation.
4: Very delayed response to stimulation, or absence of any response to stimulation.
7. RELATIONSHIP: Observer assesses the infants ability to engage in a relationship
with him/her, or with anyone present in the room, other than his/her caretaker. Relationship is assessed through attitude, visual contact, reaction to stimulation, and possible
reaction to the end of the examination session.
0: Relationship clearly and quickly established, rather positive (after a possible initial
phase of anxiety).

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3:
4:

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Relationship identiable, positive or negative, but less than described in 0.


Relationship mildly evident, delayed, positive or negative.
Doubt as to the existence of a relationship.
Absence of identiable relationship to others.

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8. ATTRACTION: The effort needed by the observer to keep in touch with the child is
assessed here, along with the pleasure initiated by the contact with the child:
0: The child attracts attention through his/her initiative and contact, generating a feeling
of interest and enjoyment.
1: There is interest towards the child, but without less pleasure than as described in 0.
2: Neutral feelings towards the child, possibly with a tendency to forget to focus on
the child.
3: Uneasy feeling towards the child, feeling of being maintained at a distance.
4: Disturbing feeling with the child, impression of a child beyond reach.
TOTAL:
LAST NAME:
FIRST NAME:
DATE: / / /
AGE: / /
MONTHS / /
DAYS
EXAMINER

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