Open Journal of Psychiatry, 2011, 1, 8-13
doi:10.4236/ojpsych.2011.11002 Published Online April 2011 (
Published Online April 2011 in SciRes.
Assessing the quality of life of children with mental disorders
using a computer-based self-reported generic instrument
Quality of life of children with mental disorders
Melanie White-Koning1, Martine Gayral-Taminh2, Valérie Lauwers-Cancès3, Hélène Grandjean2,
Jean-Philippe Raynaud2,4
1EA3035, Institut Claudius Regaud, Toulouse, France;
2INSERM, UMR 1027, Université Paul Sabatier, Toulouse, France;
3CHU de Toulouse, Department of Epidemiology and Public Health, Toulouse, France;
4CHU de Toulouse, University Department of Child and Adolescent Psychiatry, Toulouse, France.
Received 5 March 2011; revised 12 April 2011; accepted 20 April 2011.
OBJECTIVE: To assess the self-reported quality of
life (Qol) of children with various mental disorders
and compare the scores in this population with those
in children without such problems. METHODS: Self-
reported Qol was assessed using KidiQoL, a generic
computer-based tool with 44 items exploring four
domains (Physical and psychological health, Family
life, School life and Social and physical environment).
The study group consisted of 139 children (111 boys
and 28 girls) aged between 6 and 12 years (mean age
9.1 years) referred to an outpatient mental health
unit for mental disorders, 29 of whom completed the
questionnaire about 2 weeks later in order to assess
test-retest reliability. The comparison group consisted
of 130 children from the general population, aged 6
to 12 years (mean age 9.0 years) and attending main-
stream schools in the same geographical area. RE-
SULTS: The test-retest reliability of the instrument
was very good with an intraclass correlation coeffi-
cient of 0.97 for the total score and above 0.90 in all
domains. No significant differences in domain and
total scores were observed according to gender or
developmental age. Children with developmental dis-
orders or schizophrenia reported significantly lower
QoL in the Health domain than children with other
types of mental disorders. In all domains and for the
total score, the children with mental disorders re-
ported significantly lower QoL than the children from
the general population; CONCLUSION: KidIQoL
has been found suitable and psychometrically valid in
children with mental disorders. Its use could help the
assessment and adaptation of psychiatric care.
Keywords: Quality of Life; Mental Disorder; Children
In child and adolescent psychiatry, clinical assessment
remains largely focused on cognitive abilities or symp-
toms such as signs of depression, anxiety, psychosis,
learning difficulties or adaptation disorders. It is how-
ever obvious to professionals working with such chil-
dren that other dimensions of their lives should be ex-
plored and yield important information concerning their
difficulties and suffering.
The current emphasis on quality of life (QoL) reflects
this widely held view that traditional outcome measures,
including survival or presence of disabilities or physical
symptoms, do not capture the complete range of ways in
which a patient may be affected by illness or treatment.
A difficulty in the assessment of QoL is the lack of
consensus concerning its definition due to the breadth of
the concept. In 1993, a working group within the World
Health Organisation defined QoL as “an individual’s
perception of their position in life in the context of the
cultural and values systems in which they live, and in
relation to their goals, expectations, standards and con-
cerns” [24]. QoL can be seen as a multidimensional con-
struct encompassing several core domains, generally
identified as material conditions, physical status and
functional abilities, social interactions and emotional
While QoL research in adults has progressed substan-
tially in the past 25 years, QoL measurement in children
M. White-Koning et al. / Open Journal of Psychiatry 1 (2011) 8-14 9
is still relatively new. However, it has received much
greater attention in the past decade [4,6,7,10].
A literature review published in 1995 found that child
QoL was assessed by proxies in 90% of studies [4]. In
1993, the World Health Organisation (WHO) and the
International Association for Child and Adolescent Psy-
chiatry and Allied Professions (IACAPAP) jointly rec-
ommended that measures of QoL in children use subjec-
tive self-reporting wherever possible [23]. There are
however developmental issues to be taken into consid-
eration regarding children’s self-reports of QoL. The
quality of children’s reports is highly dependent on their
expressive and receptive language abilities, which vary
according to the child’s age and level of cognitive de-
velopment. Furthermore, most QoL measures require the
respondent to reply based on experiences during a spe-
cific time period (e.g. “in the past week” or “in the past
month”). The ability of a child to respond to a time
frame demand will depend on his/her memory and per-
ception of time which again vary according to his/her
level of cognitive development. Also, compared to adults
or adolescents, children have fewer experiences on
which to base their interpretation of events.
Hence it is essential that child QoL instruments be
appropriately adapted to use with children. Question-
naire length, simplicity and attractiveness of the layout,
comprehensibility of instructions and the length and
wording of individual items all contribute to improving
the clarity of paediatric QoL instruments. Children also
need to be given sufficient time to complete the ques-
tionnaire. Recent research has shown that children are
able to self-report on their well-being and functioning
reliably if the questionnaire is appropriate to their age
and cognitive level [11,15,17-19]. Children as young as
5 years have been found capable of answering questions
about their QoL [13]. Consequently, an increasing num-
ber of child QoL studies have made efforts to obtain the
children’s own perspective [6,10,14].
A problematic issue in the assessment of child QoL is
the lack of measures based on children’s own perspec-
tives as to what constitutes a life of quality. Little is
known about the relative importance that children attach
to different life states. However, it is obvious that chil-
dren do not share the same interests, life values and ex-
pectations as adults. Despite this, the vast majority of
instruments used to assess children’s QoL are largely
based on (adult) researchers conceptualisations of QoL
and some are even adaptations of instruments conceived
for assessing QoL in adults [4,10]. In recent studies, a
few researchers have obtained children’s views on the
important aspects of their life and used them to develop
QoL instruments that would be relevant to children [8,9,
Until now most studies of child QoL have involved
healthy children or children with physical diseases. Very
few studies have examined the QoL of children with
mental disorders [1-3,5,16,21]. Furthermore most of the
latter studies used parent or professional proxy-reports
of child QoL. Our team was determined to obtain self-
reports of QoL from children with mental disorders.
However the aim was also to measure these children’s
QoL in the same way and according to the same stan-
dards as for children from the general population, lead-
ing us to prefer generic instruments over specific ones. A
self-reported computer-based generic tool, KidiQoL has
been developed by a team of researchers including child
psychiatrists and methodologists. It is short and easy to
administer and has been validated in children from the
general population [12]. This paper aims to examine the
psychometric properties of this instrument in a popula-
tion of children with various mental disorders, determine
whether it is suitable for use in this population and
compare the scores in this population with those in chil-
dren without such problems.
2.1. Population
The sample consisted of 139 children (111 boys (80%)
and 28 girls) aged between 6 and 12 years (mean age 9.1
years) and referred to an outpatient mental health unit
for the following conditions: Disorders of psychological
development or Schizophrenia, schizotypal and delu-
sional disorders (ICD F80-F89, n = 55, ICD F20-F29, n =
8), (Total, n = 63, 46%), Behavioural and emotional dis-
orders (ICD F90-F98) (n = 31, 22%), Neurotic, stress-
related and somatoform disorders (ICD F40-F48) (n =
28, 20%) and mood disorders (ICD F30-F39) (n = 17,
12%). Most children (n = 84, 60%) had learning difficul-
ties yielding a lower developmental age than their
chronological age: 44 children (32%) had a develop-
mental delay of 2 years or more (The developmental age
was assessed with WPPSI-III and WISC-IV). The mean
developmental age in the population was 7.9 years. Half
of the children (n = 69, 50%) went to mainstream school,
36% (n = 50) had schooling within the mental health
care unit, while the remaining children (n = 17, 12%)
were in special classes within mainstream schools. Fi-
nally, three children did not have any form of schooling.
Of the 139 children, 29 completed the questionnaire a
second time (about 2 weeks later) in order to assess
test-retest reliability.
The comparison group consisted of 130 children from
the general population, aged 6 to 12 years (mean age 9.0
years), attending mainstream schools and living in the
same geographical area as the patient group.
opyright © 2011 SciRes. OJPsych
M. White-Koning et al. / Open Journal of Psychiatry 1 (2011) 8-14
2.2. Instrument
The KidIQoL is a generic self-reported computer-based
instrument for the assessment of quality of life in chil-
dren aged 6 to 12 years. The measure includes 44 items
covering 4 domains of quality of life: Physical and psy-
chological health (13 items), Family life (9 items),
School life (9 items) and Social and physical environ-
ment (13 items). A subscale score can be derived for
each of these four domains as well as a total scale score
summarising the whole instrument. KidIQoL is com-
pleted by the children themselves using a computer. The
child first has to enter his/her gender and age. Each item
is then presented as a sentence written out on the com-
puter screen with a gender-sensitive illustration depict-
ing the given situation (Figures 1 and 2). The child then
has to click on one of 5 boxes representing the 5 Likert-
scale responses ranging either from “entirely agree” to
entirely disagree” or from “always” to “never”, de-
pending on the type of question. The questionnaire takes
around 20 minutes for a child to complete. Each question
is coded 1 to 5, with higher scores representing better
QoL. Domain scores are constructed by taking the mean
of the item scores of the domain and linearly transform-
ing it into a score on a scale from 0 to 100. For the do-
mains including 9 items (respectively 13 items), if there
are less than or equal to 2 (respectively 3) missing values,
these are replaced by the mean of the remaining items,
otherwise the domain score is considered missing. The
total scale score is the mean of all 44 items and is con-
sidered missing if one or more domain scores are miss-
2.3. Statistical Analyses
The internal consistency of each domain and of the en-
tire scale was determined using Cronbach’s α coeffi-
cients. A confirmatory factor analysis was carried out to
determine whether the factor structure in children with
mental disorders corresponded to the four domains iden-
tified by the authors’ initial validation on ordinary chil-
dren [12]. Test-retest reliability was examined using
one-way analysis of variance and intraclass correlation
coefficients (ICC). The Spearman correlation of each
item with its own domain score (omitting that item) and
with the other domain scores was computed in order to
check the item-discriminant validity of the instrument.
Mann-Whitney and Kruskal-Wallis non-parametric
tests were used to test whether the total and domain
scores varied according to gender, chronological and
developmental age, type of mental health problem and
type of schooling. The total and domain scores of the
children with mental disorders and those from the gen-
eral population were also compared using Mann-Whit-
ney’s test.
The face validity of KidIQoL was good. Indeed the in-
strument was very favourably perceived both by the cli-
nicians and by the children themselves. Most children
were very quick to understand and use the questionnaire
and particularly appreciated its computerised format.
They seemed to find it relevant to them and enjoyed be-
ing asked about themselves. The children often asked to
do the questionnaire again during subsequent therapy
Internal consistency as estimated by Cronbach’s α was
very good for the total scores, good for the Health and
School domains and adequate for the Family and Envi-
ronment domains (Table 1). Furthermore, item-discrimi-
nant validity was satisfactory with the majority of items
correlating more strongly with their own domain than
with the other domains (ranges given in Table 1). The
test-retest reliability of the instrument was very good
with ICCs above 0.90 in all domains and ICC = 0.97 for
the total score. The confirmatory factor analysis showed
that the factor structure in our population of children
with mental disorders corresponded broadly with the
domains identified by the authors of the instrument.
We found no significant difference in domain and to-
tal scores according to gender or developmental age.
Children with developmental disorders or schizophrenia
reported significantly lower QoL in the Health domain
than children with other types of mental disorders (Table
2). However, in the other domain scores and the total
score there were no significant differences according to
type of mental problem. There were significant differ-
ences in scores according to type of schooling in all do-
mains except for the Family domain (Table 3). In the
School and Environment domains, children attending
special classes in mainstream schools reported signify-
cantly higher QoL than children in mainstream schools
or those schooled in the mental health unit. While in the
Health domain, children schooled in the mental health
unit reported significantly lower QoL than those in
mainstream schools or those in special classes in main-
stream schools. In all domains and for the total score, the
children with mental disorders reported significantly
lower QoL than the children from the general popula-
The aim of this study was to examine the psychometric
properties of KidIQoL, a self-reported QoL instrument,
in children with various mental disorders and to deter-
mine its suitability for use in such children.
In 1993, the WHO and the International Association
or Child and Adolescent Psychiatry and Allied Profes- f
opyright © 2011 SciRes. OJPsych
M. White-Koning et al. / Open Journal of Psychiatry 1 (2011) 8-14
Copyright © 2011 SciRes.
Table 1. Median, Means, Cronbach’s α and correlations for domain and total scores.
N Median MeanSD Cronbach’s α
of items with
own domain
Correlations of
items with other
ICC* for
School life 13666.7 65.0 13.9 0.76 0.25-0.74 0.003-0.43 0.95
Family life 13273.3 72.4 9.9 0.55 0.03-0.52 0.002-0.53 0.96
Physical and psychological
health 13952.3 54.5 12.0 0.79 0.25-0.60 0.03-0.40 0.90
Social and physical
environment 13975.4 74.8 8.0 0.56 0.05-0.53 0.003-0.41 0.95
Total score 13064.8 66.2 7.6 0.82 0.03-0.54 0.97
*ICC = Intraclass Correlation Coefficient.
Figure 1. Boy item example and «frequency» Lickert-type
response scale. Item: “I wake up at night”; Lickert-type re-
sponse scale: “Always, Often, Sometimes, Rarely, Never”.
Figure 2. Girl item example and «satisfaction» response scale.
Item : “I have a disability or illness that makes my life un-
pleasant”; Response scale: “I entirely agree, I agree, I do not
care, I disagree, I entirely disagree”.
sions (IACAPAP) jointly recommended that measures of
QoL in children use subjective self-reporting wherever
possible [23]. Despite this, few studies in the literature
have examined the QoL of children with mental disor-
ders, exceptions being Clark and Kirisci [5] who inclu-
ded self-reports of adolescents and Bastiaansen et al. [1]
who compared child and parent reports of QoL in a popu-
lation of children referred for psychiatric problems. The
KidIQoL is a generic tool which has been used in children
from the general population but which we also found
clinically relevant for assessing the QoL of children with
mental disorders. Compared to other tools it has the ad-
ditional strengths of being both illustrated and comput-
erised making it attractive and simple for children.
KidIQoL had good face validity; it was perceived as
relevant and enjoyable by children with various mental
disorders. The gender-appropriate pictures which are
used to illustrate each question are an essential asset,
especially for children with mental disorders, many of
whom are not fluent readers or writers and have prob-
lems understanding abstract concepts. The instrument is
easy to use in everyday clinical practice and its comput-
erised format means the data are automatically recorded,
which avoids data entry and coding errors.
Furthermore, we found that the psychometric proper-
ties of the KidIQoL were satisfactory, with good internal
consistency and satisfactory item-discriminant validity.
The test-retest reliability of the questionnaire was very
good. The factor structure of the questionnaire in chil-
dren with mental disorders was found to correspond to
the four-domain structure shown in ordinary children.
Finally, the ability of the instrument to discriminate be-
tween different groups was good, since we found that in
all four domains and overall, children with mental health
disorders reported lower QoL than children from the
general population. These results concur with those re-
ported by Sawyer et al. [21] and Bastiaansen et al. [1]
who found that children with psychiatric disorders had
lower overall QoL than children with no disorder.
We found that there was no significant difference in
median Total QoL scores or in the domain scores ac-
cording to the type of mental disorder, except for the
M. White-Koning et al. / Open Journal of Psychiatry 1 (2011) 8-14
Table 2. Median scores according to type of mental disorder (ICD 10).
disorders &
(F80-89 & F20-29)
(n = 63)
Behavioural and
emotional disorders
(n = 31)
Neurotic disorders
(n = 28)
Mood disorders
(n = 17)
test (p)
MedianIQR* Median IQR* Median IQR* Median IQR*
School life 68.9 60.0-73.3 66.7 52.5-75.6 53.3 46.7-68.9 68.9 60.0-77.8 0.11
Family life 71.1 65.0-77.5 74.2 66.3-80.0 75.6 66.7-80.0 72.9 68.9-78.9 0.44
Physical and
psychological health 49.2 43.1-58.5 55.4 47.7-66.2 57.7 46.2-67.7 56.9 49.2-66.2 0.02
Social and physical
environment 72.3 69.2-76.9 73.8 69.2-78.5 76.9 70.0-80.0 76.9 70.8-83.1 0.25
Total score 64.1 60.9-68.2 65.2 61.9-72.0 64.1 60.9-72.3 68.2 61.6-73.6 0.52
*IQR = Inter Quartile Range.
Table 3. Median scores according to type of schooling.
Mainstream school
(n = 69)
Special class in
mainstream school
(n = 17)
Schooling in mental
health care unit
(n = 50)
test (p)
Median IQR* Median IQR* Median IQR*
School life 66.7 51.1-77.8 73.3 71.1-75.6 66.7 53.3-71.1 0.03
Family life 73.3 67.5-80.0 75.6 72.5-84.4 71.1 62.2-77.8 0.08
Physical and psychological health56.9 49.2-66.2 56.9 49.2-61.5 47.7 41.5-53.8 0.0002
Social and physical environment 75.4 69.2-81.5 76.9 75.4-83.1 73.1 69.2-76.9 0.007
Total score 66.3 61.4-72.7 70.9 66.2-74.1 62.7 60.5-65.9 0.0005
*IQR = Inter Quartile Range.
Physical and psychological health domain, where chil-
dren with Developmental disorders or schizophrenia had
lower QoL than children with other disorders. Similarly,
Bastiaansen et al. [1] found no significant differences in
Total or domain PedsQL scores between diagnostic
categories, though in the Psychosocial health domain
children with Pervasive developmental disorders and
those with Mood disorders self-reported lower QoL than
those with other types of disorders.
Interestingly we found significant differences accord-
ing to type of schooling in the Total score and all domain
scores except Family life. Children who were schooled
in mental health care units reported significantly lower
QoL in the Health and Environment domains than chil-
dren who were individually or collectively integrated in
main-stream schools, while those in special classes in
main-stream schools (collective integration) reported
significantly higher QoL than the other two groups in the
School life domain and Total QoL score. This finding
sheds an interesting light on the current debate concern-
ing the best policy to adopt for the schooling of children
with special needs; however it deserves more thorough
exploration in future research projects.
An important component of the psychiatric care of
children suffering from mental disorders is to enable
them to see themselves as individuals with a personality
and opinions, and the ability and duty to make their own
choices. Thus, an instrument of self-reported QoL such
as the KidIQoL is a useful starting point in clinical prac-
tice to encourage children to express their feelings con-
cerning their well-being and overall satisfaction with life.
As the questions cover many different aspects of daily
life, clinicians will get a better idea of the child’s feel-
ings in specific areas and be able to adapt their pro-
grammes of care to the child’s development and progress
in order to help him/her to gain autonomy and a fulfil-
ing place in society.
Another advantage of the routine use of the KidIQoL
is the possibility of obtaining quantitative assessments of
children’s subjective QoL over time. This can be of par-
ticular importance when following a child’s progress in
terms of their acquisition of new cognitive or social
abilities over a period of time and as an indicator of the
success of certain changes in the child’s environment or
type of schooling for example.
opyright © 2011 SciRes. OJPsych
M. White-Koning et al. / Open Journal of Psychiatry 1 (2011) 8-14 13
There is a dearth of research on the QoL of children with
mental disorders. The KidIQoL is a computer-based il-
lustrated generic instrument of self-reported QoL for
children aged 6 to 12 years which has been found suit-
able and psychometrically valid in children with mental
disorders. Its use in everyday clinical settings has proved
useful and should be encouraged as it is likely to help
with the assessment and adaptation of psychiatric care.
The authors declare no conflict of interest.
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