Symptoms defined by parents' and teachers' ratings in attention-deficit hyperactivity disorder: changes with age.

OBJECTIVE: To determine whether Child Behavior Checklist/4-18 (CBCL) and Teacher Report Form (TRF) scores of children and adolescents with a first-time diagnosis of attention-deficit hyperactivity disorder (ADHD) are different and whether there is a similar difference in normal control subjects. METHOD: We analyzed the CBCL and TRF scores of 146 patients (124 boys and 22 girls, aged 6 to 18 years; mean age 11.0 years, SD 3.6). We analyzed the same scores for 274 age and sex-matched control subjects recruited from a nationally representative sample. RESULTS: Subjects with ADHD had significantly higher CBCL and TRF scores than control subjects. Age was significantly correlated with scores on the CBCL and TRF subscales Social Withdrawal, Somatic Complaints, and Internalization Problems; with scores on the CBCL subscale Attention Problems; and with scores on the TRF subscale Anxiety-Depression. In the group with ADHD, age was negatively correlated with scores on the CBCL and TRF subscale Externalizing Problems and with scores on the TRF subscale Aggressive Behavior. In the control group, the only significant correlation was between age and the CBCL subscale Somatic Complaints score. CONCLUSIONS: These results indicate that underdiagnosis of ADHD in childhood may cause the emergence of greater internalization problems in adolescence.     

Father–infant interaction patterns as precursors of children’s later externalizing behavior problems

AIM: This study examined the extent to which fathers' and infants' interaction behavior were related to children's externalizing behavior problems at age 8 and 11 years. METHODS: In a prospective longitudinal study of children at risk for later psychopathology, 72 fathers and their 3-month-old children were videotaped and evaluated during a standardized playing and nursing situation. Externalizing behavior problems at age 8 and 11 years were assessed using Achenbach's Child Behavior Checklist. RESULTS: In the high externalizing group, fathers were found to be less responsive and less sensitive (the latter only with respect to girls) during early interaction than fathers of the low externalizing group, while children were more positive with their fathers. Furthermore, low scores on the interaction pattern of "sensitive fathering/negative infant" and high scores on the "nonresponsive fathering or active infant" pattern were associated with more externalizing problems. CONCLUSION: These findings suggest that father and infant interaction behaviors during early infancy may predict later problem behaviors at school age, although the mechanisms underlying this relationship have yet to be identified.     

The continuity of psychopathology from early childhood to preadolescence

Objective To study the continuity of psychopathology from the age of 3–12 years. Methods In a population-based birth cohort, children’s emotional and behavioral problems were assessed at age 3 using the Child Behavior Checklist 2–3 (CBCL 2–3), and at age 12 by parents using the CBCL 11–18, and the Youth Self Report (YSR) completed by the children. Behavioral ratings were obtained from 800 subjects at both time points. Results externalizing problems at age 3 predicted both externalizing and internalizing problems among both genders in preadolescence. In girls, internalizing behavior at age 3 predicted parent-reported internalizing behavior, and associated negatively with externalizing behavior in self-reports at age 12. Aggressive behavior was found to be remarkably stable, and both aggressive and destructive behavior independently predicted a wide range of later externalizing and internalizing problems. Parent ratings of withdrawal showed stability from early childhood to preadolescence in both genders. Somatic complaints of 3-year-old girls independently predicted both externalizing and internalizing problems. Conclusions The results show the complexity of pathways in psychopathology from early childhood to preadolescence. In particular, aggressive and destructive behaviors in very early childhood predict later problems and necessitate early recognition and possible intervention at an early age. An instrument like the CBCL 2–3 is valuable in the early detection of children at risk of long-term problems.     

Association of testosterone and dihydrotestosterone with externalizing behavior in adolescent boys and girls

BACKGROUND: While an association between androgens and different types of aggression has been well documented in male offenders, the influence of androgens on externalizing behavior in adolescents at risk for antisocial behavior has not been investigated so far. METHODS: Plasma levels of the main androgen metabolites testosterone (T) and 5alpha-dihydrotestosterone (DHT) were measured in N = 87 fourteen-year-old (36 boys, 51 girls) from a prospective longitudinal study of children at risk. Externalizing behavior at age 8, 11 and 14 was assessed using the Achenbach Child Behavior Checklist (CBCL) and Teacher Report Form (TRF). RESULTS: Significant higher androgen levels (T, DHT) were found in male, but not in female adolescents with elevated scores of externalizing behavior. Moreover, boys with persistent externalizing behavior exhibited the highest levels of plasma androgens. CONCLUSIONS: There is a link between T, DHT and externalizing behavior in male adolescents at risk for psychopathology. Due to the findings of highest androgen levels in boys with persistent externalizing behavior, a role of androgens in the development of disruptive or later antisocial disorders can be hypothesized.     

The child behavior checklist broad-band scales predict subsequent psychopathology: A 5-year follow-up

OBJECTIVE: To evaluate the utility of the Child Behavior Check list (CBCL) for identifying children of parents with panic disorder or major depression at high-risk for future psychopathology. METHODS: Baseline Internalizing and Externalizing CBCL T-scores were used to predict subsequent depressive, anxiety, and disruptive behavior disorders at a 5-year follow-up in children of parents with panic disorder, major depression, or neither disorder. RESULTS: The Internalizing scale predicted subsequent agoraphobia, generalized anxiety disorder, separation anxiety disorder, and social phobia. In contrast, the Externalizing scale predicted subsequent disruptive behavior disorders and major depression. CONCLUSIONS: The convergence of these results with previous findings based on structured diagnostic interviews suggests that the CBCL broad-band scales can inexpensively and efficiently help identify children at high risk for future psychopathology within a population of children already at risk by virtue of parental psychopathology.     

Adolescents in smoking cessation treatment: relationship between externalizing symptoms, smoking history and outcome

Previous research has indicated a potential bi-directional link between youth substance use and externalizing psychiatric comorbidities. We hypothesized that the degree of externalizing symptoms predicts the likelihood of successful smoking cessation (prolonged abstinence) among adolescent smokers participating in a cessation trial. We also explored the association of externalizing symptoms with age at smoking initiation. Ninety one adolescents (mean+/-S.D.; age 15.1+/-1.4 years, cigarettes per day 18.4+/-8.1, Fagerstr?m Test for Nicotine Dependence 7.1+/-1.3) were included. The Child Behavior Checklist/4-18 and Youth Self-Report assessed the degree of externalizing symptoms. Regression analysis indicated that lower CBCL externalizing scores significantly predicted the likelihood of prolonged abstinence. Pearson's correlation analysis indicated a significant association of lower externalizing scores with later onset of smoking initiation. Our findings highlight the importance of addressing externalizing behaviors in adolescent smoking cessation programs.     

Recurrent seizures and behavior problems in children with first recognized seizures: a prospective study

PURPOSE: Children with epilepsy have high rates of behavior problems. The purpose was to describe prospectively the association of seizures and behavior problems in children with new-onset seizures. METHODS: Subjects were 224 children with new-onset seizures (aged 4-14 years) and 159 siblings (4-18 years). Caregiver's ratings of the behavior were collected 4 times: at baseline, and at 6, 12, and 24 months. During the 2-year period, 163 (73%) children had at least one additional seizure, and 61 (27%) had none. Data were analyzed by using repeated measures analysis of variance both with and without covariates [site, age, gender, race, caregiver education (years), and seizure medications]. RESULTS: On average, children had higher CBCL Total and Internalizing Behavior Problems scores across all times when experiencing recurrent seizures than when not experiencing recurrent seizures (Total Problems, p = 0.041, controlling for demographics and seizure medications). Siblings had significantly lower Total and Internalizing Problems scores than both children experiencing (Total Problems adjusting for covariates, p = 0.0001) and not experiencing recurrent seizures (p = 0.0004). Externalizing Problems scores were not significantly different among children with recurring seizures, children without recurring seizures, and siblings. CONCLUSIONS: Recurrent seizures significantly predicted behavior problems very early in the course of a seizure condition, even when key child, demographic, and seizure variables were controlled. Explanations for these findings include the possibilities that both seizures and behavior problems are caused by an underlying neurological disorder, that seizures per se disrupt behavior, or that children have negative psychological responses to seizure activity.     

Externalizing and internalizing problems in relation to autonomic function: a population-based study in preadolescents

OBJECTIVE: To investigate whether externalizing and internalizing problems are related to lower and higher heart rate (HR), respectively, and to explore the relationship of these problems with respiratory sinus arrhythmia (RSA) and baroreflex sensitivity (BRS). Moreover, to study whether problems present at both preschool and preadolescent age show stronger associations with autonomic function than those that were not. METHOD: In a population cohort of 10- to 13-year-old children (N = 931; 11.6 +/- 0.5 years; 47% boys), autonomic measurements in supine and standing position were performed at school. RSA and BRS were determined by spectral analysis. Current externalizing and internalizing problems were assessed by the Child Behavior Checklist and problems at age 4 to 5 retrospectively by the Preschool Behavior Questionnaire. RESULTS: At supine rest, current externalizing problems were associated with lower HR and higher RSA, but not with BRS and current internalizing problems with higher HR and lower RSA, but not with BRS. These results were specifically found in children with problems that were retrospectively reported to have been also present at preschool age. Standing-induced changes in autonomic parameters were unrelated to the behavioral dimensions. CONCLUSIONS: Externalizing and internalizing problems are associated with divergent autonomic patterns, suggesting autonomic underarousal and overarousal, respectively. Problems starting early in life may specifically account for this. This should be confirmed in prospective studies.     

The CBCL and the Identification of Children with Autism and Related Conditions in Brazil: Pilot Findings

The Child Behavior Checklist (CBCL)/4-18 is one of the few standardized means available for assessing child mental health in Brazil. In this context, the identification of a specific pathology such as autism by the CBCL/4-18 is relevant. To examine the validity of the CBCL/4-18 for the identification of autism, the CBCL/4-18 was applied to 101 children: 36 with autism and related conditions, 31 with other psychiatric disorders, and 34 schoolchildren. Children ranged in age from 4 to 11 years. A CBCL factor called Autistic/Bizarre and the narrow-band Thought Problems scale differentiated autistic conditions from other psychiatric disorders and schoolchildren. CONCLUSION: The CBCL/4-16 can identify autistic children in clinical and school settings in Brazil.     

Psychological adjustment of young subjects with Möbius sequence and their primary caregivers’ strain and life satisfaction: First longitudinal data

Aims/MethodsAt present, there is no information about the course of psychological adjustment in young subjects with Möbius sequence (MS) and their parents' strain and life satisfaction. To fill this gap, we performed a four-year follow-up study. Parents were anonymously asked to fill out the Child Behavior Checklist 4-18 [CBCL/ 4-18] or the Young Adult Behavior Checklist 18-30 [YABCL/ 18-30] and the Freiburger Personality Inventory-Revised [FPI-R], subscales strain and life satisfaction.Results12 males and 14 females (mean: 15.20 years, standard deviation: 3.48 years) could be included in the follow-up (response rate: 83.9%).Compared to the general population, subjects with MS showed significantly higher scores on almost all CBCL scales (exception: externalizing problems) at T1 and T2. At both study times, parental strain and life satisfaction were not significantly different from findings in the general population. No significant longitudinal changes could be found for CBLC scales, parental strain and life satisfaction.ConclusionsProblems with psychological adjustment seem to be frequent among younger subjects with MS. Therefore, careful monitoring as well as early and adequate interventions, if indicated, are crucial for subjects with MS, not only with regard to somatic complaints but also to aspects of adjustment.     

Use of and need for professional help for emotional and behavioral problems among preadolescents: a prospective cohort study of 3- to 12-year-old children

OBJECTIVE: To determine the effect of child-, parent- and family-related factors on the use of and need for mental health services by 12 years of age. METHOD: A prospective population-based questionnaire study of 1,287 first-born children was launched in Finland in 1985. The Child Behavior Checklist (CBCL) was completed by 1,086 parents when the children were aged 3 years. At the age of 12, the CBCL, the Youth Self-Report, and other potential determinants of service need and use were obtained from 908 parents and 900 children (80% response rate). RESULTS: Of the total sample, 7.2% had used professional services, and 3.3% had needed services without obtaining them. Elevated scores on the age 3 CBCL Total Problems and Externalizing scale predicted independently later service use but not perceived need of services. In cross-sectional data at age 12, parental ratings of the child's problem behavior were associated with both the need for and use of services. Poor social competence and parental distress were independently associated with use of services. CONCLUSIONS: Recognizing behavior problems in early childhood and evaluating family stress factors are important in social and health care systems designed for children.     

Problems and competencies reported by parents of Vietnamese children in Hanoi.

OBJECTIVE: To determine the distribution of behavioral and emotional problems and competencies among a sample of Vietnamese children aged 4 through 18 years living in Hanoi. METHOD: A representative community sample of 1,526 children and adolescents was selected from 2 precincts in Hanoi. Problems and competencies were assessed with the Child Behavior Checklist (CBCL). RESULTS: Vietnamese children had lower mean raw scores than U.S. norms on the CBCL's Total, Externalizing, Internalizing, and Competence scales. Boys were reported to have more externalizing problems and girls more internalizing problems. Girls' levels of internalizing problems increased significantly with age. CONCLUSION: The lower levels of problems and competencies reported in Vietnamese children may represent differences in the prevalence of psychiatric disorders, in parental perceptions of what constitutes deviant behavior, or in parental comfort with reporting psychopathological behaviors. Further research is needed to clarify the relationship between the reported behavioral and emotional problems of Vietnamese children and the presence of psychiatric disorders. From a clinical perspective, the study's results suggest that levels of problems and competencies may vary significantly between different ethnic and cultural groups. Specific clinical cutoffs used to identify children requiring further psychiatric assessment need to be established separately for different ethnic groups.     

Personality and Psychopathology in Flemish Referred Children: Five Perspectives of Continuity

The present study investigates five types of continuity of personality and internalizing and externalizing problems (i.e., structural, differential, mean-level, individual-level and ipsative continuity) in a sample of referred children and adolescents (N = 114) with a broad variety of psychological problems. Mothers were administered a child personality and psychopathology measure, i.e., the Hierarchical Personality Inventory for Children [Handleiding hiërarchische persoonlijkheidsvragenlijst voor kinderen (manual hierarchical personality inventory for children). Ghent University, Department of Developmental, Personality, and Social Psychology, Ghent, 2005] and the Child Behavior Checklist [Handleiding voor de cbcl/4–18: (Manual of the CBCL/4–18), Afdeling Kinder- en Jeugdpsychiatrie. Erasmus Universiteit Rotterdam, The Netherlands, 1996] at two measurement occasions, with a 26-months interval. Personality was substantially stable, paralleling findings for non-referred peers. Internalizing and Externalizing Problem Behavior were almost as stable as personality traits, suggesting that childhood psychopathology is more persistent than generally assumed. Strengths and limitations of the present study and implications for further research are discussed.     

A general population twin study of the CBCL/6-18 DSM-oriented scales

OBJECTIVE: To explore the contributions of genetic and environmental influences to individual variation and covariation of the Child Behavior Checklist (CBCL) DSM-oriented scales (DOS) originally proposed by Achenbach and associates in 2001. METHOD: A classic twin study of 398 twin pairs ages 8 to 17 years belonging to the population-based Italian Twin Registry, assessed by parents using the CBCL for Ages 6 to 18 (CBCL/6-18). RESULTS: Univariate analyses showed that compared with the classic CBCL/6-18 empirical subscales, the DOS have higher heritability (lowest 0.54 for Anxiety Problems, highest 0.71 for Conduct Problems) and simpler causal structure in that the phenotypic variance was satisfactorily explained by additive genetic and unique environmental factors only. Multivariate analyses showed that the causes of phenotypic correlation among the different DOS can be attributed to one common genetic factor and to two idiosyncratic environmental factors, each loading differently on the Internalizing (Anxiety and Affective Problems) and the Externalizing (Attention-Deficit/Hyperactivity, Oppositional Defiant, and Conduct Problems) CBCL/6-18 DOS. CONCLUSIONS: Several common risk factors of both genetic and environmental nature can simultaneously affect a child's proneness to develop the psychopathological signs and symptoms captured by the CBCL/6-18 DOS.     

A two-year follow-up of psychodynamic psychotherapy for internalizing disorders in children

OBJECTIVE: To evaluate short- and long-term effects of time-limited psychodynamic psychotherapy (PP) for children with internalizing disorders. METHOD: Fifty-eight outpatient children (6.3-10.9 years old), seen in a process of routine care and meeting criteria for depressive or anxiety disorder, were assigned to either active treatment or community services. Subjects were measured at baseline, after 6 months, and at a 2-year follow-up, by Children's Global Assessment Scale (C-GAS) and Child Behavior Checklist (CBCL). RESULTS: Major improvements in the experimental group were found in C-GAS and CBCL. These differences are noted at different times, with the C-GAS findings seen at 6 months and the CBCL findings at 2-year follow-up. Significant differences were found also for externalizing syndrome scales. CONCLUSIONS: PP is effective in treating internalizing disorders in routine outpatient care. The benefits of treatment are manifest both immediately and with delayed onset (sleeper effect). The finding that PP patients sought mental health services at a significantly lower rate than comparison conditions represents an important economic impact of PP.     

Parent reports of child behavior problems in young Sami children: a cross-cultural comparison

 In a general population study of 4-year-olds, using the Child Behavior Checklist (CBCL), parent reports of child behavior problems were compared in samples of 67 monoethnic Sami, 52 multiethnic Sami/Norwegian, and 63 monoethnic Norwegian children from the Sami core area in northern Norway. Mean CBCL total problem scores were low for all three groups [Sami: 21.1 (SD 15.5), Sami/Norwegian: 19.4 (SD 12.2) and Norwegian: 18.8 (SD 13.6)]. No significant differences across ethnic groups were found for the Total Problems scale and the Internalizing and Externalizing scales, nor for the syndrome scales, except for the Withdrawn scale, the Sami/Norwegian sample showing the highest scores. However, significant ethnicity × gender interactions emerged, indicating that the effect of ethnicity was different for boys versus girls. Sami mothers reported the highest and the Norwegian mothers the lowest scores for girls, whereas the opposite pattern was found for boys. Correlations between mothers' and fathers' reports were generally low. Differences in mean scale scores between pairs of parents (n = 122) were found for boys but not for girls, mothers scoring higher than fathers. The authors underline the importance of taking gender differences, age and ethnic context into account when assessing problem behavior in minority children. Methodological problems in cross-cultural assessments, including the influence of cultural norms of child behavior on parents' problem ratings, are discussed. Accepted: 18 January 2000     

Disruptive behavior in young children: what does it mean?

OBJECTIVE: To examine how the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC 0-3) primary diagnoses, Parent-Infant Relationship Global Assessment Scale, and Child Behavior Checklist/2-3 (CBCL/2-3) externalizing and internalizing symptoms augment the DSM-III-R/IV and guide treatment. METHOD: 82 children aged 18 to 47 months, who presented with disruptive behavior to an early childhood psychiatry clinic, were diagnosed using DSM-III-R/IV, DC 0-3, and the CBCL/2-3. RESULTS: Children with DSM-III-R/IV disruptive disorders or attention-deficit/hyperactivity disorder were diagnosed with DC 0-3 regulatory disorders, disorders of affect, and traumatic stress disorder. Clinically significant externalizing and internalizing symptoms co-presented in 45.1% of the children. Of children with disorders of affect, 41.2% had relationships categorized as disordered, contrasting with 21.1% of those with traumatic stress disorder and 10.3% of those with regulatory disorders. Increasingly disordered relationships were significantly correlated with externalizing and internalizing symptoms, and children with disordered relationships were 3.6 times more likely to have clinically significant levels of internalizing symptoms. CONCLUSION: In these children with disruptive behaviors, co-presentation of externalizing and internalizing symptoms is most common. Those with increased relational risk had more externalizing and internalizing symptoms and more disorders of affect.     

Four-year follow-up of an epidemiological sample

In this 4-year follow-up of behavioral/emotional problems in an epidemiological sample of 1,200 children originally aged 4 to 12 years assessed with the Achenbach Child Behavior Checklist (CBCL), high stability in the level of CBCL total problem scores was found. Stability of problem behavior was equally substantial for ages 4 to 12 and both sexes. Aggressive and other externalizing behaviors showed the highest stability. Even in children as young as 4 to 5 years, aggressive and attentional problems showed considerable stability. The results of the present study were informative with respect to methodology in indicating clearly that employing a mailing survey for obtaining parent reports on behavioral/emotional problems resulted in the selective exclusion of a group of especially problematic children who were recovered when parents were interviewed at home.     

Continuity and change of psychopathology from childhood into adulthood: a 14-year follow-up study

OBJECTIVE: To test the 14-year continuity and change of behavioral and emotional problems from childhood into adulthood. METHOD: For 1,615 children and adolescents aged 4 to 16 years from the general population, parents completed the Child Behavior Checklist (CBCL) at initial assessment. At follow-up 14 years later, subjects completed the Young Adult Self-Report (YASR), and their parents completed the Young Adult Behavior Checklist (YABCL). RESULTS: Of the subjects who were initially classified as deviant, 14 years later 41% were classified as deviant according to their YABCL Total Problem score, and 29% according to their YASR Total Problem score. Intrainformant (CBCL/YABCL) Withdrawn, Social Problems, Delinquent Behavior, and Aggressive Behavior scores, and cross-informant (CBCL/YASR) Anxious/Depressed, Thought Problems, and Delinquent Behavior scores were independent predictors of general levels of problem behavior. CONCLUSIONS: Childhood and adolescent problems persisted to a considerable degree into adulthood, although the majority of children who were deviant at initial assessment could not be regarded as deviant 14 years later. Children who were adolescents at initial assessment (12-16 years) showed higher stability of problem behaviors than subjects who were children at initial assessment (4-11 years).     

Does HPA-axis activity mediate the relationship between obstetric complications and externalizing behavior problems? The TRAILS study

To examine whether HPA-axis activity mediates the relationship between obstetric complications (OCs) and externalizing behavior problems, and to investigate whether this model is different for boys and girls. In a population-based cohort of 1,768 10- to 12-year-old early adolescents, we assessed the cortisol awakening response and evening cortisol levels. Externalizing behavior problems were assessed using the Child Behavior Checklist and the Youth Self-Report. OCs were retrospectively assessed in a parent interview. OCs significantly predicted externalizing behavior problems, but OCs did not predict HPA-axis activity. Thus, the mediation model was not supported. In addition to the relationship between HPA-axis activity and externalizing behavior problems, which is specific for girls, there is also a relationship between OCs and externalizing behavior problems. However, these two mechanisms are not related to each other indicating that HPA-axis activity is not a mediator in the relationship between OCs and externalizing behavior problems. Future research should focus on understanding the mechanism through which OCs cause externalizing behavior problems.