Comparison of internalizing and externalizing symptoms in children with attention-deficit hyperactivity disorder with and without comorbid tic disorder.

This study examined the relation between internalizing and externalizing symptoms in two groups of prepubertal boys (with and without multiple chronic tic disorder) with diagnosed attention-deficit hyperactivity disorder (ADHD). Parents and teachers completed the Child Behavior Checklist (CBCL) and Teacher's Report Form (TRF), respectively. Children were carefully evaluated for the absence of a chronic tic disorder. Boys with ADHD and chronic multiple tic disorder (ADHD/+tics) received significantly higher (p = .0032, Bonferroni correction) scores for the Anxious/Depressed, Thought Problems, and Attention Problem scales of the CBCL and the Delinquent Behavior, Thought Problems, and Somatic Complaints scales of the TRF than did boys without chronic tic disorder (ADHD/-tics). Although many of the individual items that differentiated (p < .05) the two groups of boys pertained to behaviors that characterize motor tics, obsessions, or compulsions, the ADHD/+tics group exhibited higher rates of anxious behavior (CBCL) and obscene language (TRF) than did the ADHD/-tics group. Anxiety/depressive symptoms were associated with aggressive/oppositional behavior in both samples. Children with mild tic disorder were more similar (CBCL) to ADHD/-tics boys than they were to children with more severe tic disorder. The relatively higher rate of comorbidity in the ADHD/+tics group suggests that tics may be a marker for more severe symptomatology in clinic-referred samples of children with ADHD. Furthermore, these data suggest that it is not the presence, per se, but rather the severity of tic disorder that is associated with higher rates of emotional and behavioral disturbances.     

Normative Data and Psychometric Properties of the Child Behavior Checklist and Teacher Rating Form in an Iranian Community Sample

Objective

The objective of this study was to determine the normative data and psychometric properties of the parent and teacher rating form of the child behavior checklist (CBCL) in an Iranian community sample.

Methods

A sample of 6-12 year old students was randomly selected from ten elementary schools in Tehran, Iran. The parent''s and teacher''s versions of CBCL were accomplished. Clinical interview and the kiddie schedule for affective disorders and schizophrenia – present and lifetime version, Persian version (K-SADS-PL-PV) were used to evaluate the validity and the cut-off point of CBCL and the teacher rating form (TRF).

Findings

Among 600 recruited students with mean age of 9.11 years (SD=1.45), 54.16% were girls (n=325). Girls had significantly lower scores in Attention Problems, Delinquent Behavior, Aggressive Behavior, Externalizing and Total Problems than boys (P<0.01). The relation was significant between the CBCL Internalizing and students'' ages (β=0.124, P=0.002). The Internal consistency, the correlation among the CBCL and TRF scales, and the inter-rater correlations for CBCL/TRF scales were good to high for most indices and subscales. Based on the receiver operating characteristics (ROC) analysis the best convergences were between the CBCL Attention Problems subscale and attention deficit hyperactivity disorder (ADHD) diagnosis, the CBCL Total Problems and any disorders, the CBCL Externalizing and ADHD+ODD diagnosis. The sensitivities and specificities of the CBCL subscales were higher than the TRF except for Externalizing/ADHD+ oppositional defiant disorder (ODD) which was reverse.

Conclusion

These results support the multicultural CBCL/TRF findings. CBCL is a useful instrument to consider ADHD and any disorders in community samples.     

Associations between Different Diagnostic Approaches for Child and Adolescent Psychopathology

Objective: To test the convergence between the empirical-quantitative approach of the Child Behavior Checklist (CBCL) and the clinical-diagnostic approach of the DSM. Method: The parent version of the NIMH Diagnostic Interview Schedule for Children (DISC), version 2.3, was administered after completion of the CBCL for 231 children and adolescents consecutively referred to an outpatient mental health clinic. Results: Of the subjects with a DSM-III-R diagnosis, 60% scored in the clinical range of the CBCL total problem score. The Withdrawn scale predicted affective and anxiety disorders. The Somatic Complaints scale predicted anxiety and mood disorders and Attention Deficit Hyperactivity Disorder. The Anxious/Depressed scale predicted anxiety and mood disorders and, to a lesser extent, disruptive behavior disorders. The Social Problems scale predicted Oppositional Defiant Disorder. The Attention Problems scale was the only significant predictor of "pure" Attention Deficit Hyperactivity Disorder (ADHD). The Aggressive Behavior scale predicted several disruptive behavior disorders, and Major Depression. The Delinquent Behavior scale was strongly associated with Conduct Disorder. Conclusions: Empirically based CBCL scale scores and DISC-P based DSM-III-R diagnoses converged. However, both approaches do not converge to a degree that one approach can replace the other. Instead, combining both approaches may be valuable by adding information from one approach that is not captured by the other.     

Psychological and social adjustment after pediatric liver transplantation as a function of age at surgery and of time elapsed since transplantation

The study assessed psychological and social adjustment to pediatric liver transplantation in 101 patients aged 4-16 years who had undergone transplantation 2-10 years earlier. Each parent completed the Child Behavior Check List (CBCL) independently and answered a transplantation questionnaire assessing psychosocial issues. Most children scored within the normal range for both parts of the CBCL (i.e. Behavioral Problems and Social Competences). The impact of age at transplantation and of time elapsed since transplantation were examined. Earlier transplantation was associated with subsequent higher scores for Aggressive Behavior and Sex Problems, with lower scores for Activities and Competences, and with more parental anxiety concerning their child's health. The longer the time elapsed since transplantation, the more mothers rated high levels on the Somatic complaints, Anxiety/depression, Competence, and Social activity CBCL scales for their child. Parents reported talking more about the transplantation with their children with increasing time following transplantation. This suggests that transplantation remains an important event even after long periods of time from the transplant event. Finally, despite the difficulties encountered, more than 80% of the parents considered the transplantation had been beneficial to their child.     

Developmental course of psychopathology in youths with and without intellectual disabilities

BACKGROUND: We aimed to describe similarities and differences in the developmental course of psychopathology between children with and without intellectual disabilities (ID). METHODS: Multilevel growth curve analysis was used to analyse the developmental course of psychopathology, using the Child Behavior Checklist (CBCL), in two longitudinal multiple-birth-cohort samples of 6- to 18-year-old children with ID (N = 978) and without ID (N = 2,047) using three repeated measurements across a 6-year period. RESULTS: Children with ID showed a higher level of problem behaviours across all ages compared to children without ID. A significant difference between the samples in the developmental courses was found for Aggressive Behaviour and Attention Problems, where children with ID showed a significantly larger decrease. Gender differences in the development of psychopathology were similar in both samples, except for Social Problems where males with ID showed a larger decrease in problem behaviour across time than females with ID and males and females without ID. CONCLUSIONS: Results indicate that children with ID continue to show a greater risk for psychopathology compared to typically developing children, although this higher risk is less pronounced at age 18 than it is at age 6 for Aggressive Behaviour. Contrary to our expectations, the developmental course of psychopathology in children with ID was quite similar from age 6 to 18 compared to children without ID. The normative developmental trajectories of psychopathology in children with ID, presented here, can serve as a yardstick against which development of childhood psychopathology can be detected as deviant.     

Social competence and behavior problems in premature children at school age

Social competence and behavior problems of 87 children born weighing less than 1501 g were measured using the Child Behavior Checklist when the children were 7 to 8 years old. Both premature boys and girls had significantly lower Social Competence scores than the normative samples of their respective sexes. Only premature boys had significantly higher Behavior Problems scores, with significantly higher scores on behaviors associated with conduct disorders. Premature children in each of three social class groups had significantly lower Social Competence scores and higher Behavior Problems scores than normative children. Furthermore, there was an interaction between prematurity and social class on Behavior Problems scores, with the greatest discrepancy in scores between premature and normative children in the lower-class group. Relative to other predictors, IQ score best explained Social Competence scores and family stability best explained Behavior Problems scores in the premature sample.     

Screening for DSM-IV externalizing disorders with the Child Behavior Checklist: a receiver-operating characteristic analysis

BACKGROUND: This study examines the diagnostic accuracy of the CBCL syndrome AS scales for predicting DSM-IV Attention Deficit-Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder with or without Conduct Disorder (ODD/CD). METHODS: The sample included 370 children (187 probands and 183 siblings) participating in a family genetic study of attention and aggressive behavior problems. Univariate and stepwise logistic regression analyses were used to derive models for predicting two diagnostic conditions: ADHD and ODD/CD. RESULTS: The Attention Problems syndrome significantly predicted ADHD, and ODD/CD was significantly predicted by the Aggressive Behavior syndrome. Both scales demonstrated good diagnostic accuracy, as assessed through receiver operating characteristics analyses. Cut-point analyses confirmed the utility of low T-scores, 55 on the respective syndromes, for efficiently discriminating cases from noncases. CONCLUSIONS: CBCL syndromes display good diagnostic efficiency for assessing common externalizing disorders in children.     

Relative contribution of attention-deficit hyperactivity disorder, obsessive-compulsive disorder, and tic severity to social and behavioral problems in tic disorders

The aim of this study was to investigate social and behavioral problems related to attention-deficit hyperactivity disorder (ADHD), obsessions and compulsions, and tic severity in children with a tic disorder. Parents of 58 children with a tic disorder with and without different forms of ADHD completed the Child Behavior Checklist (CBCL) and the Children's Social Behavior Questionnaire. Patients with a tic disorder with primarily hyperactive-impulsive ADHD had the highest questionnaire scores, patients with primarily inattentive ADHD had medium scores, and patients without ADHD had the lowest scores. On most subscales, significant part correlations with ADHD severity, but not tic severity, were obtained. Severity of obsessions and compulsions was independently correlated with the CBCL Thought Problems subscale but not with most other subscales. There was no significant correlation between tic severity and ADHD severity. Thus, in patients with a tic disorder, the presence and severity of ADHD are the main predictors of associated behavioral and social problems.     

Adoption of romanian children in The Netherlands: behavior problems and parenting burden of upbringing for adoptive parents

Seventy-two Dutch adoptive parents of 80 Romanian children completed the Child Behavior Checklist (CBCL), the Nijmegen Questionnaire for the Upbringing Situation (NQUS), and participated in a semistructured interview (response 83%). Thirty-four percent of the adopted children scored in the clinical range on Externalizing and 36 % on Total Problems scales. Significantly more children who were at least two years at placement and had stayed less than five years in the adoptive family received scores in the clinical range on almost all CBCL clinical clusters. Nevertheless, the adoptive parents judge their upbringing situation positive (NQUS).     

Prevalence and correlates of psychopathology in a sample of deaf adolescents

AIMS: To examine prevalence and correlates of psychopathology in deaf adolescents using a multi-method multi-informant approach. METHODS: Data for the study came from checklist assessments by parents (Child Behavior Checklist (CBCL)) and teachers (Teacher's Report Form (TRF)) of 70 deaf adolescents aged 13 to 21 years, from semi-structured clinical interviews of the adolescents (Semi-structured Clinical Interview for Children and Adolescents (SCICA)), and from expert ratings of dossier data. RESULTS: The percentages of Total Problems scores in the borderline clinical range in this population as found with the CBCL, TRF and SCICA are 28%, 32% and 49-63% respectively. Expert dossier ratings identified psychiatric caseness in 49% and DSM-classifications in 46% of the adolescents (primary classifications: emotional disorder 27%, behavioral disorder 11%, other disorder 7%). Cross-informant agreement between single ratings and expert dossier ratings was better than agreement between single ratings. Logistic regression analyses revealed that low IQ, a signing mode of communication and a history of three or more physical disorders were associated with psychiatric caseness. CONCLUSIONS: Findings suggest a high prevalence of psychopathology in the population studied and argue for a special focus on the early detection of significant emotional and behavioral problems as well as a multi-informant approach to the assessment of disorder in deaf children and adolescents. The correlational findings support the view that it is not deafness per se that contributes to psychiatric problems.     

The CBCL as a screen for psychiatric comorbidity in paediatric patients with ADHD

Aims: To examine the informativeness of the Child Behavior Checklist (CBCL) as a screening tool to identify comorbid and non-comorbid cases of attention deficit hyperactivity disorder (ADHD) in a paediatrically referred population. It was hypothesised that specific scales of the CBCL would help identify specific comorbidities within ADHD cases in the primary care setting. Methods: The sample consisted of children and adolescents 6–17 years old of both genders with ADHD (n = 121). A receiver operating curve (ROC) approach was used to determine which CBCL scales best differentiated between ADHD cases with and without its comorbidities with conduct, anxiety, and mood disorders. Results: ROC analysis showed that the CBCL Delinquent Behavior and Aggressive Behavior scales predicted the structured interview derived diagnoses of conduct and bipolar disorder, the Anxious/Depressed and Aggressive Behavior scales predicted major depression, and the Anxious/Depressed and Attention problems scales predicted anxiety disorders. Conclusions: These results extend to a paediatrically referred population with previously reported findings in psychiatric samples documenting good convergence between structured interview diagnoses and syndrome congruent CBCL scales. These findings support the utility of the CBCL as a screening tool for the identification of psychiatric comorbidity in ADHD youth in the primary care setting.     

The CBCL as a screen for psychiatric comorbidity in paediatric patients with ADHD.

AIMS: To examine the informativeness of the Child Behavior Checklist (CBCL) as a screening tool to identify comorbid and non-comorbid cases of attention deficit hyperactivity disorder (ADHD) in a paediatrically referred population. It was hypothesised that specific scales of the CBCL would help identify specific comorbidities within ADHD cases in the primary care setting. METHODS: The sample consisted of children and adolescents 6-17 years old of both genders with ADHD (n = 121). A receiver operating curve (ROC) approach was used to determine which CBCL scales best differentiated between ADHD cases with and without its comorbidities with conduct, anxiety, and mood disorders. RESULTS: ROC analysis showed that the CBCL Delinquent Behavior and Aggressive Behavior scales predicted the structured interview derived diagnoses of conduct and bipolar disorder, the Anxious/Depressed and Aggressive Behavior scales predicted major depression, and the Anxious/Depressed and Attention problems scales predicted anxiety disorders. CONCLUSIONS: These results extend to a paediatrically referred population with previously reported findings in psychiatric samples documenting good convergence between structured interview diagnoses and syndrome congruent CBCL scales. These findings support the utility of the CBCL as a screening tool for the identification of psychiatric comorbidity in ADHD youth in the primary care setting.     

Child Behavior Checklist Juvenile Bipolar Disorder (CBCL-JBD) and CBCL Posttraumatic Stress Problems (CBCL-PTSP) scales are measures of a single dysregulatory syndrome

Background: The Child Behavior Checklist Juvenile Bipolar Disorder (CBCL‐JBD) profile and Posttraumatic Stress Problems (CBCL‐PTSP) scale have been used to assess juvenile bipolar disorder (JBD) and posttraumatic stress disorder (PTSD), respectively. However, their validity is questionable according to previous research. Both measures are associated with severe psychopathology often encompassing multiple DSM‐IV diagnoses. Further, children who score highly on one of these scales often have elevated scores on the other, independent of PTSD or JBD diagnoses. We hypothesized that the two scales may be indicators of a single syndrome related to dysregulated mood, attention, and behavior. We aimed to describe and identify the overlap between the CBCL‐JBD profile and CBCL‐PTSP scales. Method: Two thousand and twenty‐nine (2029) children from a nationally representative sample (1073 boys, 956 girls; mean age = 11.98; age range = 6–18) were rated on emotional and behavior problems by their parents using the CBCL. Comparative model testing via structural equation modeling was conducted to determine whether the CBCL‐JBD profile and CBCL‐PTSP scale are best described as measuring separate versus unitary constructs. Associations with suicidality and competency scores were also examined. Results: The CBCL‐JBD and CBCL‐PTSP demonstrated a high degree of overlap (r = .89) at the latent variable level. The best fitting, most parsimonious model was one in which the CBCL‐JBD and CBCL‐PTSP items identified a single latent construct, which was associated with higher parental endorsement of child suicidal behavior, and lower functioning. Conclusions: The CBCL‐JBD profile and CBCL‐PTSP scale overlap to a remarkable degree, and may be best described as measures of a single syndrome. This syndrome appears to be related to severe psychopathology, but may not conform to traditional DSM‐IV classification. These results contribute to the ongoing debate about the utility of the CBCL‐JBD and CBCL‐PTSP profiles, and offer promising methods of empirically based measurement of disordered self‐regulation in youth.     

Confirmation that Child Behavior Checklist clinical scales discriminate juvenile mania from attention deficit hyperactivity disorder

OBJECTIVE: To determine whether boys meeting diagnostic criteria for juvenile mania and attention deficit hyperactivity disorder (mania-ADHD) may be distinguished from boys with ADHD alone on a range of clinical and family variables. METHODOLOGY: Boys aged 9-13 years with mania-ADHD (n = 25), ADHD alone (n = 99), or no psychiatric diagnosis (n = 27) were compared on parent and teacher report Child Behavior Checklists (CBCL) and Conners Questionnaires, self-report CBCLs, patterns of comorbidity, intellectual functioning, and family variables. RESULTS: Mania-ADHD subjects had significantly higher mean ratings than ADHD only subjects on the parent CBCL for the Withdrawn, Thought Problems, Delinquent Behavior and Aggressive Behavior scales and significantly higher rates of comorbid depression, anxiety and psychotic symptoms. Other variables did not distinguish the mania-ADHD and ADHD only groups. CONCLUSIONS: These data confirm previous research indicating that the CBCL may be used to assist in the clinical identification of manic children.     

Continuity of behavioral and emotional problems from pre-school years to pre-adolescence in a developing country

Background:  All previous longitudinal community studies assessing the continuity of child behavioral/emotional problems were conducted in developed countries.
Method:  Six hundred and one children randomly selected from a Brazilian birth cohort were evaluated for behavioral/emotional problems through mother interview at 4 and 12 years with the same standard procedure – Child Behavior Checklist (CBCL).
Results:  CBCL Total Problem score presented a medium stability ( r  = .42) with externalizing problems showing higher stability and more homotypic continuity than internalizing problems. Of the children presenting deviant scores at the age of 4, only 31% remained deviant at the age of 12 ( p  < .001). A deviant CBCL Total Problem score at 12 years old was predicted by Rule-Breaking Behavior [OR = 7.46, 95% CI 2.76–20.19] and Social Problems [OR = 3.56, 95% CI 1.36–9.30] scores at 4 years of age. Either Rule-Breaking or Aggressive Behavior – externalizing syndromes – were part of the predictors for the three broad-band CBCL scores and six out of the eight CBCL syndromes.
Conclusions:  Behavioral/emotional problems in preschool children persist moderately up to pre-adolescence in a community sample. Externalizing problems at the age of 4 comprise the developmental history of most behavioral/emotional problems at pre-adolescence. Our findings concur with findings from developed countries and are quite similar for continuity, stability and predictability.     

Social and emotional problems in children with neurofibromatosis type 1: evidence and proposed interventions.

OBJECTIVE: To describe social and emotional problems in children and adolescents with neurofibromatosis type 1 (NF1) and propose interventions. Our hypothesis is that children with NF1 will have significantly more social and emotional problems, compared with their unaffected siblings and children in the general population. STUDY DESIGN: Forty-three children with NF1 and 22 unaffected siblings (ages 5 to 18 years) were assessed with a standardized test completed by parents and teachers (the Child Behavior Checklist). RESULTS: As with other aspects of NF1, there was variable expressivity. However, when rated by parents, children with NF1 had significantly more problems in comparison with test norms or unaffected siblings on 7 of 8 scales: Social Problems, Attention Problems, Anxiety/Depression, Withdrawal, Thought Problems, Somatic Complaints, and Aggressive Behavior. Children with NF1 also scored lower than unaffected siblings on measures assessing sports and other activities. Teachers reported fewer differences. CONCLUSIONS: We propose interventions in the form of information for parents; early screening and treatment for speech, motor, and cognitive problems; and an increased level of intervention to prevent and treat psychologic problems, including systematic screening with standardized tests.     

Across the continuum of attention skills: a twin study of the SWAN ADHD rating scale

INTRODUCTION: Most behavior checklists for attention problems or attention deficit/hyperactivity disorder (ADHD) such as the Child Behavior Checklist (CBCL) have a narrow range of scores, focusing on the extent to which problems are present. It has been proposed that measuring attention on a continuum, from positive attention skills to attention problems, will add value to our understanding of ADHD and related problems. The Strengths and Weaknesses of ADHD symptoms and Normal behavior scale (SWAN) is such a scale. Items of the SWAN are scored on a seven-point scale, with in the middle 'average behavior' and on the extremes 'far below average' and 'far above average'. METHOD: The SWAN and the CBCL were completed by mothers of respectively 560 and 469 12-year-old twin pairs. The SWAN consists of nine DSM-IV items for Attention Deficit (AD) and nine DSM-IV items for Hyperactivity/Impulsivity (HI). The CBCL Attention Problem (AP) scale consists of 11 items, which are rated on a three-point scale. RESULTS: Children who had a score of zero on the CBCL AP scale can be further differentiated using the SWAN, with variation seen between the average behavior and far above average range. In addition, SWAN scores were normally distributed, rather than kurtotic or skewed as is often seen with other behavioral checklists. The CBCL AP scale and the SWAN-HI and AD scale were strongly influenced by genetic factors (73%, 90% and 82%, respectively). However, there were striking differences in genetic architecture: variation in CBCL AP scores is in large part explained by non-additive genetic influences. Variation in SWAN scores is explained by additive genetic influences only. CONCLUSION: Ratings on the SWAN cover the continuum from positive attention skills to attention and hyperactivity problems that define ADHD. Instruments such as the SWAN offer clinicians and researchers the opportunity to examine variation in both strengths and weaknesses in attention skills.     

Severe affective and behavioural dysregulation is associated with significant psychosocial adversity and impairment

Background: Recently, a highly heritable behavioral phenotype of simultaneous deviance on the Anxious/Depressed, Attention Problems, and Aggressive Behavior syndrome scales has been identified on the Child Behavior Checklist (CBCL–Dysregulation Profile, CBCL‐DP). This study aims to investigate psychosocial adversity and impairment of the CBCL‐DP. Methods: A total of 9024 patients aged 4–18 years were assessed using the CBCL, and the axes V and VI of ICD‐10. Results: ANOVA revealed significant differences regarding psychosocial adversity and impairment between patients with CBCL‐DP phenotype and the clinical control group, patients with attention problems, and patients with attention problems and additional anxious/depressed symptoms as assessed by the CBCL. Patients with CBCL‐DP showed significant psychosocial adversity and impairment. However, in most cases patients with aggressive behavior showed equal psychosocial adversity as patients with CBCL‐DP. Conclusions: Findings suggest the CBCL‐DP phenotype to be associated with significant psychosocial adversity and impairment either as a cause or an effect of the syndrome. Clinicians should carefully address psychosocial adversity and impairment with particular attention to the adversity and impairment of adolescents with CBCL‐DP.     

The behavior profile of children and adolescents with short stature

The relation between behavior profiles and short stature was assessed in 311 children and adolescents with various diagnoses. The mean Child Behavior Checklist (CBCL) and Youth Self-Report (YSR) profile of the entire group of children with growth deficiency significantly exceeded population norms on all scales and scores. However, there were no significant differences between five major diagnostic groups across CBCL scales. Neither age, gender, socioeconomic status, nor severity of short stature had any effect on the various CBCL and YSR scores. Correlations between parent (CBCL) and child (YSR) scores were significant, though only at a low to medium level. It was concluded that probably short stature per se, rather than a specific diagnosis, has an impact on behavioral adaptation.     

Intelligence and achievement of children referred following sexual abuse

OBJECTIVE: Little is known about the prevalence of intellectual and academic problems in sexually abused children. Such problems may have significant implications for their management. This study examined the prevalence of such problems in a population of Australian children referred for sexual abuse evaluation. The study also assessed the clinical utility of the Parents' Evaluation of Developmental Status (PEDS) questionnaire as a screening tool for learning and developmental problems in this population. METHODS: Over a 12-month period, children referred for sexual abuse evaluation to the Mater Children's Hospital Child Protection Unit were enrolled and background demographic and abuse related data collected. The children then completed standardized psychometric assessments. Their parents completed Child Behavior Checklists (CBCL) and PEDS questionnaires. Day care providers and schoolteachers completed the corresponding Caregiver or Teacher Report Forms (TRF). RESULTS: A total of 21 of the 35 eligible children completed the assessment during the study period. Mean scores for intelligence and academic achievement were within the average range. However, three (14%) of the tested children were intellectually impaired and three (14%) showed academic underachievement. Sixty-two per cent of children had problems in the clinical range on the CBCL and 33% on the TRF. The PEDS showed a sensitivity of 64%, specificity of 60% with a positive predictive value of 77%. CONCLUSION: In this population of referred children, over one quarter showed problems with intellectual impairment or academic under achievement. Most of these children were not receiving learning support at school. A high index of suspicion is therefore required when assessing sexually abused children for comorbid intellectual and learning problems.