Child and Adolescent Mental Health Volume **, No. *, 2009, pp.

****

doi: 10.1111/j.1475-3588.2008.00518.x

The Reliability and Validity of KiddieSchedule for Affective Disorders and

Schizophrenia - Present and Life-time
Version - Persian Version
Zahra Shahrivar1,2, Maryam Kousha1,4, Shirin Moallemi1, Mehdi
Tehrani-Doost1,2 & Javad Alaghband-Rad1,2,3
1

Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran.
E-mail: sharivar@sina.tums.ac.ir
2
Psychiatry and Psychology Research Center, Tehran University of Medical Sciences, Tehran, Iran
3
Dalhousie University, Halifax, Canada
4
Department of Psychiatry, Gillan University of Medical Sciences, Rasht, Iran

Background: The validity and reliability of a Persian version of the Kiddie Schedule for Affective Disorders and
Schizophrenia-Present and Lifetime Version (K-SADS-PL-P) was evaluated. Method: The K-SADS-PL-P was
administered to 102 inpatients (mean age = 15.3 yrs, SD = 1.81) in a child and adolescent psychiatric ward.
The psychometric properties were evaluated in comparison to the results of clinical diagnosis. Results: The
K-SADS-PL-P showed good-to-excellent concurrent validity in diagnosing current major disorders. Test-retest
reliabilities of most of the current diagnoses were also good to excellent. Conclusion: The Persian version of
the K-SADS-PL provides reliable and valid youth psychiatric diagnoses.
Key Practitioner Message:
Concurrent use of diagnostic tools and clinical evaluation will improve diagnoses of mental disorders in
children and adolescents
The Persian version of the K-SADS-PL can be used as a valid and reliable diagnostic tool in evaluating
mental problems in Persian speaking youths
The clinical interviews are more likely to miss major diagnoses whereas the structured method is more
likely to pick them up
Keywords: K-SADS-PL; Persian version; validity; reliability

Introduction
Making valid and reliable psychiatric diagnoses has
always been a challenge. Psychometric instruments,
developed for clinical and research purposes, have
affected the traditional approaches of recruiting and
evaluating psychiatric patients that mainly relies on
clinical interview and projective methods (McClellan &
Werry, 2000). Diagnostic instruments are widely used to
document the natural course of disorders and response
to treatment. The aim is to obtain an objective and replicable diagnosis, comparable to the gold standard
psychiatric diagnosis. However, many researchers
believe that the most valid diagnoses should integrate
data from all available sources by using either the best
estimate (Leckman et al., 1982) or PLASTIC (prospective, longitudinal, all sources, treatment, impairment
and clinical presentations) methods (Young et al., 1987).

Structured and semi-structured interviews have been

developed to reduce the variability in information
derived from clinical interviews, and thereby to improve
the reliability of the gathered information (McClellan &
Werry, 2000). Among the interviewer-based instruments, the Schedule for Affective Disorders and
Schizophrenia for School-Age Children (K-SADS) has
been studied frequently (Ambrosini, 2000). The present
episode version (K-SADS-P; Chambers et al., 1985) has
been used in numerous clinical, naturalistic follow-up,
treatment,
psychobiological
family-genetic
and
epidemiological studies of affective and other child
psychiatric disorders. The present and lifetime version
(K-SADS-PL) has been adapted from the present
episode version and assesses the severity of current
symptoms as well as the lifetime status of child and
adolescent psychiatric disorders. Kaufman et al. (1997)
developed the K-SADS-PL from the K-SADS-P after the

 2009 Association for Child and Adolescent Mental Health.

Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

Zahra Shahrivar et al.

4th edition of DSM was published. It is appropriate

for epidemiological studies but is not as sensitive
at evaluating treatment response because its scoring
characteristic is dichotomous for lifetime/current
diagnosis and symptoms, and does not include a broad
assessment of symptom severity (Ambrosini, 2000).
The K-SADS-PL has excellent inter-rater reliability
and results comparable to semi-structured and fully
structured child diagnostic interviews (Kaufman et al.,
1997). The test-retest reliability kappa coefficients are in
the excellent range for present and lifetime diagnosis of
major depressive disorder (MDD), bipolar disorder,
anxiety disorder, conduct disorder (CD) and oppositional
defiant disorder (ODD); and in the good range for present
diagnosis of post traumatic stress disorder (PTSD) and
attention deficit hyperactivity disorder (ADHD) (Ambrosini, 2000; Kaufman et al., 1997). The concurrent validity
of both the skip-out criteria and the diagnoses generated
with the K-SADS-PL is well supported. However, despite
the fact that we often need to administer an independent
diagnostic instrument for clinical, educational or particular research needs, the authors of the K-SADS-PL do
not recommend that it can be administered as a solo
instrument. Rather they recommend that it can be used
as part of a comprehensive assessment battery together
with rating scale data from both parents and children
and, whenever possible, teachers.
There are over 20 foreign translations of the K-SADSPL (Kaufman & Scheweder, 2003). It has been validated
as a semi-structured instrument in other countries like
Korea, Israel, Mexico, Greece and Spain.
Kim et al. (2004) used the Korean version and clinical
diagnoses of 91 participants from outpatient clinics to
evaluate its validity. They reported consensual validity
of good-to-excellent for ADHD, fair for tic and oppositional defiant disorders, and poor to fair for anxiety and
depressive disorders. They found significant correlations between the Korean K-SADS-PL and Korean Child
Behaviour Checklist (K-CBCL) that provided additional
support for the concurrent validity.
The inter-rater reliability and consensual validity of
the Hebrew translation of the K-SADS-PL were evaluated in 57 adolescents admitted to two psychiatric units
in Israel, and showed good-to-excellent reliability and
validity of diagnoses (Shanee, Apter & Weizman, 1997).
The inter-rater reliability of the Spanish version of
K-SADS-PL for 40 psychiatric outpatients (aged 6 to
17 years) was between good and excellent for affective,
anxiety and conduct disorders using the Cohens kappa
coefficient (Ulloa et al., 2006).
A pilot inter-rater reliability study of K-SADS-P with
Greek children and adolescents showed that the kappa
statistic of the diagnosis for depressive disorders was
0.90 and inter-rater reliability of assessment of anxiety
symptom was lower (r = 0.59) than that of depressive
disorders. The kappa for conduct disorders was also
high (K = 0.90) (Kolaitis et al., 2003).
There was a need for a reliable and valid psychiatric
instrument for evaluating psychiatric diagnoses in Iranian children and adolescents. Persian is the official
language in Iran, Tajikistan and Afghanistan. A large
number of people who live in the United States, Europe
and many other parts of the world speak Persian as
their first language, so a Persian speaking psychiatrist
would find it very helpful to use a valid and reliable

structured interview. We translated the K-SADS-PL into

Persian and evaluated its reliability and validity in a
clinical sample of children and adolescents with mental
health problems.

Methods
Participants
The sample consisted of children and adolescents who
were consecutively admitted in the child and adolescent
psychiatric ward of a referral university psychiatric
hospital in Tehran. The patients were evaluated by
trainee psychiatrists, and patients history of psychiatric and medical problems as well as school performance
were sought. The patients whose IQs were below 70
according to their educational records were excluded
from the study. In addition, children with active psychosis or severe agitation were excluded since they were
not cooperative with administration of the K-SADS.
Informed consent was obtained from the parents and
assent was obtained from the patients. The research
protocol was approved by the university ethics committee, in accordance with the Helsinki Declaration.

Interviewers
The interviewers were seven child and adolescent psychiatry fellows who had been practicing in child and
adolescent psychiatry for 12 months. All underwent
appropriate training regarding the use of the K-SADSPL, consisting of a two day workshop given by a child
and adolescent psychiatrist. The trainees observed how
the K-SADS-PL was administered to patients and their
parents before they themselves administered it under
the supervision. Finally, all the trainees independently
scored the K-SADS-PL while they observed it being
administered by the trainer. This process was repeated
3 times, which was not sufficient to obtain full interrater reliability but the calculated diagnostic agreement
among the raters was 95.2% for lifetime diagnosis of
bipolar disorder. Diagnostic agreements were 77%,
71%, 28.5% and 14.8% for present diagnoses of specific
phobia, bipolar disorder, generalised anxiety disorders
(GAD) and PTSD, respectively.

Measures
Translation and back translation of K-SADS-PL
The K-SADS-PL was translated into Persian by a psychiatrist and a child and adolescent psychiatrist who
were both assistant professors of psychiatry. Then it
was back-translated into English by a bilingual general
physician. The back translation version was reviewed
and compared to the original version by a second child
and adolescent psychiatrist. The translated sentences
of the Persian version were then revised and edited by
two expert child and adolescent psychiatrists. The
completed version of K-SADS-PL-P was preliminarily
administered to a number of inpatient children and
their parents at the child and adolescent psychiatry
ward to evaluate its feasibility. After the ultimate
review, the instrument was brought to use in the study.
K-SADS-PL is capable of generating 32 DSM-III-R
and DSM-IV Axis I child and adolescent psychiatric
disorders. Diagnoses are scored as definite, probable

Persian Version of K-SADS-PL

(greater than or equal to 75% of symptom criteria met),
or not present. The different components of the
K-SADS-PL are described comprehensively in Kaufman
(1997) and Ambrosini (2000).
K-SADS-PL diagnoses were made according to DSM-IV
diagnostic criteria for the presence of symptoms. The sub
threshold symptoms were not considered as a diagnosis.

Procedure
Each patient and their parents underwent a comprehensive psychiatric assessment by a child and adolescent psychiatric fellow. All other information such as
teachers reports and school documents, inpatient files,
physicians reports was also considered. Then, a boardcertified child and adolescent psychiatrist interviewed
and evaluated the patient for a best estimate diagnostic standard based on DSM-IV diagnostic criteria.
All the patients were interviewed using the K-SADSPL-P in their first week of admission. The interviewers
were blind to the clinical diagnoses of the patients. The
parents were interviewed first if the patient was a child;
vice versa if the patient was an adolescent. In case
of disagreement between the parents and the childs
accounts, the difference was discussed with them to
obtain their most agreed account. As recommend by the
developers of the K-SADS-PL, the interviewer had the
final word on the most appropriate item.
To obtain the test-retest reliability, 32 patients were
randomly selected from patients who had agreed to take
the second interview at the beginning of the recruitment. Retest interviews were conducted at one-week
intervals, blind to the results of the initial interview and
all other information about the child.

Statistical analysis
The data were analysed using STET SPSS 11.5. The
kappa statistics were applied to examine the reliability
and concurrent validity of the K-SADS-PL-P. The kappa
coefficients were interpreted as excellent (k > 0.75),
good (k = 0.59, t = 0.74), fair (k = 0.4, t = 0.58) and
poor reliability (k < 0.4) (Landis & Koch, 1977). If there
were an insufficient number of cases (< 5) to justify
kappa statistics, percent agreement was used to generate the reliability and validity estimates (Cohen,
1960). Sensitivity, specificity, and the likelihood ratio
(positive/negative) were evaluated for the threshold
diagnoses of K-SADS-PL-P using the Chi-square test to
compare clinical and K-SADS-PL-P diagnoses.

Results
Diagnostic profile of the sample
The participants were 102 children and adolescents,
aged 9 to 18 years. The mean age was 15.3 years
(SD = 1.81). Fifty-one of them were male (50%). Ninety
percent of the interviewed parents were biological
mothers, between 35 and 58 years of age. Other interviewed caregivers were fathers or grandparents.
Table 1 shows the prevalence of psychiatric disorders
based on clinical evaluation and K-SADS-PL-P. Overall
similarity is observed between the most prevalent diagnoses by the two methods. However, several disorders
displayed a higher prevalence on K-SADS-PL-P as compared to the clinical diagnosis, for instance, ODD, anxi-

Table 1. Prevalence of psychiatric disorders based on clinical

diagnosis and K-SADS-PL-P (N = 102)
Clinical
diagnosis

K-SADSPL-P

Disorder

No.

No.

Attention deficit
hyperactivity disorder
Oppositional defiant disorder
Conduct disorder
Major depressive disorder
Bipolar disorder
Psychotic disorder
Schizophrenia
Brief psychotic disorder
Generalised anxiety disorder
Separation anxiety disorder
Obsessive compulsive disorder
Post traumatic stress disorder
Panic disorder
Agoraphobia
Specific phobia
Social phobia
Conversion disorder
Tic disorder
Tourette disorder
Enuresis
Encopresis
Substance use disorder

32

31.4

35

34.3

4
5
3
80
28
4
3
2
0
9
1
0
0
0
0
1
5
3
3
0
2

3.9
4.9
2.9
78.4
27.5
3.9
2.9
1.9
0
8.8
0.9
0
0
0
0
0.9
4.9
2.9
2.9
0
1.96

16
11
5
82
28
4
0
11
0
17
10
2
4
0
2
0
8
0
4
0
9

15.7
10.8
4.9
80.4
27.5
3.9
10.8
0
16.7
9.8
1.9
3.9
0
1.9
0
7.8
0
3.9
0
8.8

ety disorders, MDD, and substance use disorder (SUD).

The majority of patients met the criteria for bipolar disorder. The mean age of the patients who had bipolar
disorder (based on the clinical diagnosis) was 15.6 years.
Forty-eight percent of them were female (N = 41).
The results of the K-SADS-PL-P showed that 20% of
patients had pure bipolar disorder on present diagnoses, and 25% on lifetime diagnoses. The majority of
patients with bipolar disorder met the criteria for
multiple current diagnoses (43%, 25% and 4.8% had
respectively one, two and three comorbid disorders.)
The most prevalent diagnoses comorbid with bipolar
disorder were ADHD (41% current, 33% past), and
psychosis (30% current, 12% past). The prevalence
rates of disorders comorbid with bipolar disorder based
on clinical evaluation and the results of the K-SADS-PL
were respectively, 35% and 41% for ADHD, 2.5% and
12.2% for CD, 7.5% and 13.4% for obsessive-compulsive disorder (OCD), 2.5 and 8.5% for tic disorders.
The K-SADS-PL-P showed that the rates of ODD,
panic disorder, GAD, PTSD, phobias and SUD in
these patients were 13.4%, 2.5%, 9.8%, 12.2%, 2.4%
and 11%, respectively but these comorbidities were not
detected by clinical diagnoses. There was a rate of 10%
for pervasive developmental disorders in these patients
that would be an important finding of clinical evaluation, which is not covered by K-SADS-PL interview.

Validity
Kappa statistics were used to evaluate the concurrent
validity of the K-SADS-PL-P by comparing its diagnoses
with the clinical diagnoses. Tables 2 and 3 show the
validity of present and lifetime diagnoses respectively.
Kappa values for current diagnoses of psychosis, bipolar
disorder and ADHD fell into the excellent range. Kappa

Zahra Shahrivar et al.

Table 2. Validity of current diagnoses by K-SADS-PL-P (N = 102)

Diagnosis
Attention deficit hyperactivity disorder
Oppositional defiant disorder
Conduct disorder
Major depressive disorder
Bipolar disorder
Psychotic disorder
Generalised anxiety disorder
Obsessive compulsive disorder
Tic disorder
Post traumatic stress disorder
Substance use disorder

Number

Kappa

P value

Sensitivity (%)

Specificity (%)

LR +

LR )

35
16
11
5
82
28
11
17
8
10
9

0.80
0.25
0.46
0.74
0.82
0.85
0.28
0.48
0.59
0.17
0.34

<0.000
<0.001
<0.000
<0.000
<0.000
<0.000
<0.000
<0.000
<0.000
0.002
<0.000

90
75
80
100
97
89
100
77
80
100
100

91
86
92
97
81
95
91
89
95
91
93

10
5.35
10
33.3
10.77
17.8
11.11
7
16
11.11
14.28

0.10
0.29
0.21
0
0.03
0.11
0
0.25
0.21
0
0

Note. LR+ =positive likelihood ratio; LR) = negative likelihood ratio

Table 3. Validity of lifetime diagnoses by K-SADS-PL-P (N = 102)

Diagnosis
Attention deficit hyperactivity disorder
Oppositional defiant disorder
Conduct disorder
Bipolar disorder
Generalised anxiety disorder
Obsessive compulsive disorder
Enuresis
Tic disorder
Post traumatic stress disorder
Substance use disorder

Number

Kappa

P value

Sensitivity (%)

Specificity (%)

LR +

LR )

40
15
6
39
11
14
13
6
8
6

0.74
0.16
0.52
0.19
0.28
0.56
0.21
0.90
0.20
0.23

<0.000
0.042
<0.000
0.007
<0.000
<0.000
0.005
<0.000
0.001
0.007

93
50
60
45
100
77
66
100
100
50

85
86
96
86
91
92
88
98
93
86

6.2
3.57
15
3.21
11.11
9.62
5.5
50
14.28
3.57

0.08
0.58
0.41
0.63
0
0.25
0.38
0.58

Table 4. K-SADS-PL-P test-retest reliability data (N = 32)

Number
Diagnosis
Attention deficit hyperactivity disorder
Oppositional defiant disorder
Bipolar disorder
Psychotic disorder
Obsessive compulsive disorder

Current

Current

Lifetime

Agreement %

12
6
24
9
5

15
6
8
2
3

93
93
71
87
90

coefficients for lifetime diagnoses were excellent for tic

disorder, good for ADHD and fair for OCD and CD.
Sensitivities of the threshold present diagnoses by
K-SADS-PL-P ranged from 0.66 to 1 (highest sensitivity
for MDD, GAD, PTSD, and SUD; and lowest sensitivity
for enuresis). Specificities were consistently high (above
90%) in nearly all diagnostic categories. Positive and
negative likelihood ratios demonstrated good results in
most current and past diagnoses.

Test-retest reliability
Test-retest reliabilities of current diagnoses were
excellent for ADHD and ODD, and good for OCD and
psychotic disorders. Kappa statistics of lifetime diagnoses were good in ADHD and ODD, and fair in bipolar
disorder (Table 4).

Discussion
This study was conducted with a group of Iranian
children and adolescent inpatients to evaluate the

Lifetime
Kappa (p)

0.87
0.77
0.38
0.64
0.67

(<0.000)
(<0.000)
(0.02)
(<0.000)
(<0.000)

Agreement %
87
90
75
96
93

Kappa (p)
0.75
0.62
0.47
0.65
0.84

(<0.000)
(<0.000)
(0.007)
(<0.000)
(<0.000)

validity and reliability of the Persian version of K-SADSPL. Although general agreement was found between the
K-SADS-PL-P and clinical evaluation in several diagnoses there were major differences in their prevalence.
Anxiety disorders (GAD, PTSD, Phobias) were underdiagnosed by clinical evaluation compared to the
K-SADS-PL-P. The prevalence of SUD, OCD, CD, and
ODD diagnoses on clinical evaluation was nearly half
the respective prevalence identified by the K-SADS-PL-P.
These findings suggest that unstructured clinical
interviews are more likely to miss on some major diagnoses, especially if they are comorbid with other diagnoses. It is possible that clinicians are more likely to
pay attention to most severe and impairing present
disorders; therefore, they relate many symptoms or
complaints to the major diagnosis, and do not probe for
further symptoms or other diagnoses. Since many of
these underdiagnosed disorders have internalising
symptoms, they would not be obvious unless they are
surveyed directly by the clinicians. When they remain
undiagnosed, the child would be at higher risks of

Persian Version of K-SADS-PL

developing major psychiatric disorders and impairment
of function in many domains.
It is possible that most diagnostic agreements are
found in psychosis, bipolar disorder, and ADHD
because of their display of more overt symptoms that
would not go unnoticed by parents and teachers. High
rates of comorbidity warrant more accurate probing for
other psychiatric disorders in patients with a major
disorder as the natural history, prognosis, and treatment interventions of comorbid disorders would differ
substantially. This fact was very prominent in patients
with bipolar disorder, characteristics of the majority of
the participants in this study.
The general agreement between the K-SADS-PL-P
and clinical diagnoses was acceptable (Kappa greater
than 0.4 for most diagnoses). In some cases (ODD, CD,
schizophrenia, psychotic disorders, OCD, enuresis, and
tic disorders) the specificity was greater than the sensitivity. The resulting number of fewer false positives is
an important consideration in research.
The K-SADS-PL-P was sensitive at diagnosing
patients with ADHD, MDD, bipolar disorder, GAD,
PTSD, and SUD. Therefore it can be used as a diagnostic and not as a screening instrument in epidemiological studies. The accepted sensitivity and specificity
of the diagnoses based on the K-SADS-PL-P findings in
the current study may be due to our method of patient
evaluation (using parents, teachers and physicians
reports, file data, clinical history and interview, observation and other instruments). Although validating
K-SADS-PL-P was the main aim of this study,
comparisons of the clinical diagnoses with structured
interviews were also interesting.
There are some differences between our results and
those of the other researchers. The K-SADS-PL-P
showed a good-to-excellent validity in diagnosing major
disorders including psychotic and bipolar disorder,
ADHD, schizophrenia, and MDD. The validity was fair
for tic, enuresis, OCD; and poor for the rest of the disorders. The K-SADS-PL-Korean version, however,
showed fair-to-good kappa coefficients for ADHD, tic
disorders and OCD. This difference may be due to differences in the sampling and study method. The Korean
research was done in the outpatient setting comparing
the K-SADS-PL-K with the results of the K-CBCL. Since
the prevalence of diagnoses is different in outpatient
and inpatient subjects, the results of kappa statistics
may vary. Analysis of the results of test-retest reliability
statistics in our study showed good to excellent kappa
coefficients in a significant number of present and lifetime diagnoses.
A similar study administered K-SADS-PL on psychiatric inpatients in Israel (Shanee et al., 1997) with
comparable results. Their subjects were 57 adolescents
of comparable age to participants in this study. Older
patient age may be an important factor that would ease
data collection by the interviewer. Reported Kappa values for the consensual validity of the Israeli study
ranged from 0.73 to 1.00 for most of the major psychiatric disorders (depressive disorders, anxiety disorders,
behavioural disorders and tic disorder); except for
phobia (Kappa = 0.48). An inpatient study setting may
be easier to conduct due to availability of patients and a
longer time of evaluation, as well as providing more
comprehensive information from multiple informants

and sources before a best estimate clinical diagnosis

can be reached.
Ghanizadeh, Mohammadi and Yazdanshenas (2006)
investigated psychometric properties of a Persian
translation of the K-SADS-PL in an outpatient clinical
sample of children and adolescents (N = 109) in Iran,
with a good-to-excellent consensual validity in all psychiatric disorders. It was highest for panic disorder,
conduct disorder and simple phobia. They reported
sufficient validity and test-retest reliability, and goodto-excellent sensitivity, specificity, positive and negative
predictive validity for nearly all of the disorders. Testretest reliabilities of ADHD, ODD, and tic disorder were
0.81, 0.67, and 0.56, respectively.

Limitations
We did not apply any concurrent diagnostic scales to be
compared with the results of K-SADS-PL-P. Our samples were restricted to inpatients, the majority of whom
had bipolar disorder and therefore the results might be
different from work with more diverse outpatient or
community samples. The interviewers were psychiatry
fellows doing a two year subspecialty on child and
adolescent psychiatry. Their clinical judgment and
estimations of signs and symptoms of the disorders
may have influenced the accuracy of diagnoses. In most
of the published studies on administration of the
K-SADS-PL, the interviewers were bachelor or masters
level clinicians (Kaufman et al., 1997; Kim et al., 2004;
Ghanizadeh et al., 2006).

Acknowledgements
We are grateful to Drs. J. Mahmoudi Gharaei, S.H.
Mousavi, M. Khademi, F. Riahi and S.H. Amiri for
administering the K-SADS-PL-P and to Drs. H.R Naghavi and Molavi for their translation and back translation
of the K-SADS-PL-P. This research was supported by
the Psychiatry and Clinical Psychology Research Center
of Tehran University of Medical sciences.

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