Lack of Rating Scale Normalization and a Socioeconomically Advantaged Population Limits the Generalizability of Preadolescent Transgender Findings
The article by Olson et al1 exploring the mental health of preadolescent transgender children residing in families that are supportive of their identity attempted to address questions Olson recently raised in a Clinical Perspectives piece published in the Journal of the American Academy of Child and Adolescent Psychiatry.2 We read the current article in Pediatrics with great interest, and their effort was laudable. An enhanced understanding of the symptoms and phenomenology of transgender preadolescents is critical, as this material could inform interventions for this marginalized population. Olson et al ambitiously examined symptoms of anxiety and depression in both preschool-aged and early school-aged children. Their approach, however, which included a wide developmental swathe combined with a narrow socioeconomic sample, raises concerns about the meaning and generalizability of their findings.
One challenge when looking at depression and anxiety in preadolescents, particularly in preschool-aged children, is having adequate tools with sufficient validity and reliability to study these symptoms. In the investigation by Olson et al,1 transgender children between the ages of 3 and 12 years were compared with age-matched control subjects. The child participants were not surveyed; their parents completed proxy assessments by using the Patient Reported Outcomes Measurement Information System developed by the National Institutes of Health. We noted that the institutes, in their description of the psychometric properties of this tool, indicated that this proxy scale for depression and anxiety is validated only for use in children between the ages of 5 and 17 years.3 Olson et al, however, used this instrument across their entire cohort, with 30% of their study population between the ages of 3 and 5 years. This method means that data from approximately one-third of the sample were from an age group in whom the scale had not been validated, which is problematic in terms of interpretation of the results.
In addition, we noted that the population studied, although ethnically diverse, was heavily skewed to a more financially advantaged group. We observed that 44% of families had a household income greater than $125 000. This income level was above the 80th percentile for the nation, which starts at $100 000.4 Given the linkage that exists between lower socioeconomic standing and poorer outcomes in children’s mental health,5 we wondered what the results would be if a sample that was more representative of the nation were used. Might the lack of detected psychopathology be related as much to the wealth and privilege of the families observed?
Overall, we commend Olson et al1 on their effort to bring data to bear about our understanding of this understudied group. As they do, we remain curious regarding the relationship, if any, between transgender and psychopathology of childhood, particularly in preschool-aged children. We would advocate, however, for utilization of normalized scales in looking at the age under study and for identifying a population that more accurately reflects the clinical population most children’s mental health providers typically serve.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Olson KR,
- Durwood L,
- DeMeules M,
- McLaughlin KA
- DeNavas-Walt C,
- Proctor BD
- Copyright © 2016 by the American Academy of Pediatrics