To our knowledge, this is the first validation of a screening scale for children aged 3 to 6 years old, with a cross-cultural validation component, for use in humanitarian contexts. The PSYCa 3–6 enables the rapid screening of children and can be administered by non-specialists. The results of this study suggest that the Hausa version of the PSYCa 3–6 is a reliable and a valuable tool for screening psychological distress in children 3 to 6 years old. The tool was acceptable to caregivers and interviewers (after training and piloting). The sample of patients for this validation was large compared to other validation studies further strengthening our results
[13, 37, 42, 60].
Screening tools provide an important means to facilitate addressing the mental health needs of children in humanitarian emergencies and contexts. Difficulties of young children may remain unnoticed or undetected by both local and international health actors
 and may have short and/or long term developmental consequences
[8, 45, 62, 63]. Screening children provides a means to identify those in need of additional evaluation and eventual care as well as recognizing the limited resources available in these contexts. The reduction from a 40 to 22-item scale also provides additional encouragement that the scale could be administered to an often large number of children in a relatively short period of time. The simple administration of the screening scale also provides additional awareness and understanding of the overall status of the population for health care workers addressing the situations. In humanitarian contexts, a part from the acute phase of an emergency, the tool could also be used to identify difficult to reach children (due to either distance or isolation for example) and refer only those in need of additional evaluation to health structures. However, it is important to highlight that this tool allows for the identification of children requiring further evaluation, but the lack of mental health professionals remains. As with all public health interventions, identification of children in need does not unfortunately always follow with their receipt of appropriate care. Greater investments are needed to ensure that children mental health needs are addressed, and certainly that they are only screened if appropriate care is available
We would like to highlight two key points for discussion, especially relevant for future validation studies. First, the translation process was long and involved a linguistic specialist, anthropologist, psychiatrist and psychologist. We first attempted a classical translation/back translation procedure
[13, 42, 66–70], but due to significantly differences concerning written and spoken Hausa, we used independent translations resolved by discussion and pilot testing.
Second, due to the lack of previously cross-cultural validated scales in Hausa, we chose to use a classic individual interview by a psychologist as our gold standard
[47, 69, 70]. Two major types of assessment of mental disorders are used in epidemiological studies: semi structured clinical interviews and lay-administered structure diagnostic questionnaires
. To date, there has not been agreement the most appropriate validation method for global mental health research with children
[22, 42, 72, 73]. Although use of a clinical interview appeared here the most rigorous choice in this context as opposed to using another tool. The psychologist, trained in cross-cultural psychology and mental health care in children based their diagnosis on ICD-10 classification. To strengthen the clinical interviews, qualitative research concerning child development, child rearing, psychological difficulties in Hausa culture was conducted
. Concordance between the clinical interview and the PSYCa 3–6 suggest that use of the ICD-10 did not influence the results presented here.
An apparent limitation is that we do not present a traditional psychometric validation. The traditional validation process (item analysis, factor analysis, etc.) of a psychometric tool was developed in the absence of a gold standard
. The objective of the PSYCa 3–6 is to screen subjects who need further evaluation for psychiatric/psychological care. In an ideal situation, the clinician decides, after an interview, if such a care is required. Our gold standard was the clinician’s answer to the question: “does the child need psychological/psychiatric care?”. For this reason, we validated the PSYCa 3–6 as compared with the above question and classical statistics. Most other screening tools in medicine are based on the same methodology; this is the case for example for scores of gravity in intensive care units such as the APACHE score
, validated against mortality rather than with psychometric tools. After secondary evaluations have been completed, the factor structure of the PSYCa 3–6, corresponding to different clinical conditions should be investigated. The internal consistency may be viewed as a limitation from a psychometric perspective. However, as the PSYCa 3–6 is a screening tool for psychological difficulties, the scale is not one-dimensional to ensure the detection of psychological difficulties in several area of psychopathology. As the PSYCa 3–6 includes several domains, this is not unexpected.
An additional limitation concerns the test-retest and interrater reliability. Both were estimated from interviews performed on the same day. Time between the different interviews is problematic since short interval are prone to recall bias, while long intervals risk being associated with the clinical evolution of the subject evaluated.
Finally, we used initially a cut-off of 17, based on the results of previous use of the scale
[36, 40]. This number was calculated on 40 items, the initial version, scoring up to 80 (2 points per item). As previously documented, cut-off scores established with Western child populations are not necessarily comparable in others settings
[27, 43]. After reduction of the scale and analysis, we refined the cut-off to 8/9. The cut-off requires further analysis in subsequent validations to assure stability in other cross-cultural contexts.