The Child Behavior Check List Usefulness in Screening for Severe Psychopathology in Youth: A Narrative Literature Review

Abstract

Objective:

This article will review the use of the CBCL to diagnose youth with psychopathological disorders focusing on: ADHD, Mood Disorders, Autism Spectrum disorders, and Disruptive Disorders.

Method:

Using a narrative review approach, we investigate the usefulness of the CBCL as a screening tool to detect childhood onset psychopathology across different diagnostic syndromes.

Results:

The available literature supports the use of the CBCL for ADHD screening and as a measure of ADHD severity. While some studies support a specific profile linked with childhood bipolar disorder, replication studies for this profile found mixed results. The CBCL was also found to be useful in screening for patients presenting with Autism Spectrum Disorders, Conduct Disorder, and Childhood Bipolar Disorder all of which presents with more severely impaired scores.

Conclusion:

The CBCL holds promise as a screening tool for childhood psychopathology.

Keywords

Child Behavior Check List (CBCL)ADHD dysregulated profile conduct disorder autism spectrum disorder

Introduction

The Child Behavior Check List (CBCL) is a screening instrument used to assess a child’s internalizing and externalizing problems as reported by their parents. Developed by Achenbach and Resorcla (2001) as part of The Achenbach System of Empirically Based Assessment (ASEBA) its psychometric properties have been well studied (Achenbach et al., 2008; Nakamura et al., 2008).

Both clinicians and researchers have longed to find a way to better screen and allocate the scarce resources available worldwide in child and adolescent psychiatry (Biederman et al., 2020). Treatment options have widened in the last decades to address different levels of psychopathology. Some mild forms of impairment can be addressed with straightforward psychosocial and/or pharmacological interventions, but more severe forms of psychopathology generally require a combined approach with expert psychopharmacological and psychosocial interventions (Biederman et al., 2020). Comorbidity and psychosocial adversity bring clinical complexity which raises triage questions regarding the prioritization of patients and allocation of limited services.

The CBCL has been cited across numerous publications as a cost effective and reliable screening tool with cross-cultural validation to identify a variety of psychopathological syndromes. The CBCL has been used across the diagnostic spectra as a screening method for detecting specific syndromes, to indicate severity of psychopathology and as an indication for the use of specific psychopharmacological treatments. Biederman et al. (2020) have contributed significantly to this evidence base. In this review article we investigate the work of Joseph Biederman MD and the evidence supporting the use of the CBCL as a tool for diagnostic screening of children and adolescents across the psychopathological spectrum with a special focus on ADHD, Mood Disorders, Autism Spectrum disorders, and Disruptive Disorders (Conduct disorders and Oppositional disorders). We hypothesize that the CBCL could be a useful screening tool to detect childhood onset psychopathology across different diagnostic syndromes.

Methodology

We searched Pubmed, PsychInfo, and Google Scholar and chose representative publications which illustrate the evidence-based use of the CBCL scales and subscales for screening of youth psychopathology with an exhaustive focus on Dr Biederman work and selected other works. We focused mainly on papers on ADHD, Mood disorders, Autism Spectrum disorders, and Disruptive disorders screening using the CBCL.

Results

CBCL and ADHD

ADHD is one of the most common diagnoses seen clinically in child and adolescent psychiatry with the lifetime prevalence of 3.4% worldwide (Polanczyk et al., 2015). Biederman et al. (2020, 2021) have contributed extensive research on using the CBCL to advance the understanding of this neurodevelopmental disease in children and adolescents. Based on several studies, Biederman et al. (2020, 2021) showed that the CBCL is a valid and useful measure of ADHD symptom severity, comorbidity, and impairment and could be a useful and cost-effective screening method for ADHD as well as comorbid psychopathological conditions. Evidence from community, school, and clinical samples showed that among youth suffering from ADHD, comorbidity is common (Biederman et al., 2005): mood (depressive and bipolar) 15% to 75%, disruptive (conduct and oppositional) 30% to 50%, and anxiety disorders 20% to 30% (Biederman et al., 2005).

To address comorbidity with emotional dysregulation in ADHD, Faraone et al. (2019) developed a conceptual model of ADHD based on the notions of emotional impulsivity (EI) and deficient emotional self-regulation (DESR) as aspects of emotional management and as defined by combined subscales of the CBCL (Faraone et al., 2019). EI is defined in the model as “fast rising, rapid onset, with unusually high reactivity” in emotionally evocative situations. DESR arises after the phase of emotional generation and refers to a “slower than normal return of activated emotions” to baseline. In their model, Faraone et al. (2019) propose three prototypes of ADHD based on the presence of EI and/or DESR. ADHD-prototype 1 presents with high EI and deficient DESR. ADHD-prototype 2 presents with low EI and deficient DESR. ADHD-prototype 3 presents with high EI and effective self-regulation.

With an ADHD sample (N = 314) using the DSM 5 taxonomy and CBCL outcomes, Katsuki et al. (2020) distinguished, through hierarchical cluster analysis, four profiles of dimensions of ADHD: high internalizing-externalizing problems (IE), aggression-externalizing problems (AE), inattention-internalizing problems (II), and less psychopathology (LP). The different profiles were also linked to medication potency and complexity and could provide interesting avenues to understand ADHD as a dimensional spectrum disorder entity.

Volk et al. used a subtype of cluster analysis called a Latent Class Analysis (LCA) on a sample of 1,358 twin pairs of children assessed both by the MAGIC (Missouri Assessment for Genetics Interview for Children) interview used to collect parental report on child psychopathology and the CBCL, to assess the natural occurrence of ADHD symptoms and phenomenology. The hypothesis that comorbidity with Conduct Disorder, Oppositional Defiant Disorder, or Major Depression would increase the severity of impairment of patient with ADHD was also examined. In their study Volk et al. (2006) found three distinct ADHD subgroups that aligned well with the DSM IV taxonomy: Severe combined (impulsive-aggressive and inattentive) type, mild combined, and severe inattentive. In their study they found that the mild combined subtype, although often underdiagnosed had significant impairment in academic performance, cognitive performance, and need of specialized education. Regarding comorbidity they conclude that, “impairment is largely due to ADHD symptoms alone and is not exacerbated by the presence of comorbid CD, ODD, or depression.”

Overgaard et al. (2023) in a study of 707 children (381 boys and 326 girls) showed that the use of six items from the CBCL DSM-oriented scale for ADHD (can’t concentrate, can’t sit still; can’t stand waiting; demands must be met immediately; gets into everything; quickly shifts activities) could be used in a stepped screening to provide early detection of ADHD amongst pre-school children. The study showed that by using a two staged screening method using the CBCL and a more stringent symptom threshold the CBCL showed more accuracy in identifying children with persistant ADHD symtoms across time all the while reducing false positives rates.

CBCL and Mood Disorders

Biederman et al. (2009) pioneered the notion that children with ADHD can also suffer from bipolar disorder, reporting that up to 20% of children with ADHD may present with comorbid mania (Wozniak et al., 1995). A series of reports from this group (Biederman et al., 2009; Faraone et al., 2005; Mick et al., 2003) demonstrated that a specific profile of CBCL subscales consisting of the aggregate subscales of Attentive problem, Aggressive behaviors, and Anxiety-Depression problems (CBCL-A-A-A profile) can be associated with pediatric bipolar disorder (Biederman et al., 2021; Faraone et al., 2005). This profile has variably been termed the CBCL-Pediatric bipolar disorder profile (CBCL-PBD), the CBCL-Dysregulated Profile (CBCL-DP) as well as the CBCL-BP/DP (DiSalvo et al., 2023).

The CBCL-DP is a profile derived from three different subscales that covers aspects of a dysregulation construct: an affective component (Anxiety and Depressive problems), a behavioral component (Aggressive problems), and a cognitive component (Attention problems; Keefer et al., 2020). Recent evidence supports the association of the CBCL-BP/DP (Biederman et al., 1995, Mick et al., 2003) with a diagnosis of pediatric bipolar disorder. In a recent meta-analysis, DiSalvo et al. (2023) report that an aggregate T-scale score of 210 or greater (representing an average of 2SDs from normal) of the of the three CBCL subscales Anxiety/Depression, Attention, and Aggressive behavior is associated with a diagnosis of pediatric bipolar disorder. DiSalvo et al. (2023) found that youth presenting with a diagnosis of BP were at “significant increased odds of having a positive CBCL-BP/DP profile when compared with those with ADHD, DBD, anxiety/depression, and controls.” Conversely, those with a positive CBCL-BP/DP score were at increased odds of having a diagnosis of BP compared with those without that elevation.

In a longitudinal study, Biederman et al. (2009) found that patients with a positive CBCL-PBD profile follow-ed up over 7 years later had significantly increased risk for bipolar disorder (36% vs. 22%, p = .04), depression (56% vs. 29%, p < .001), conduct disorders (60% vs. 27%, p = .006), and psychiatric hospitalization (73% vs. 13% by age 25, p < .001) but not significantly different for multiple anxiety disorders, substance used disorders, or oppositional disorders (Biederman et al., 2009).

A different group, using the data from a 23-year longitudinal investigation of youth at high risk of major mood disorder, Meyer et al. (2009) showed that youth who presented with the CBCL-BPD phenotype (N = 16) were at increased risk for various psychiatric outcomes including bipolar disorders, anxiety disorders, ADHD, and cluster B personality disorders and performed at significantly lower levels of social and occupational functioning versus those without (N = 81). These investigators found that the CBCL-PBD profile was stable throughout childhood and identified youth at risk for impairment, psychiatric comorbidity, and suicidality.

Other replication studies have reported mixed results regarding the correlation specifically between pediatric bipolar disorder and the CBCL-DP (Biederman et al., 2013; Holtmann et al., 2008; Mbekou et al., 2014). A longitudinal study using the CBCL-DP profile on a sample of 80 patients initially referred for behavioral problems showed no significant association between the CBCL-DP score and Conduct Disorder, Anxiety disorder, substance use, or hospitalization rates (Masi et al., 2015). The study showed that, instead, a lower Children Global Assessment Scale (C-GAS) was a “predictor of CD, hospitalization, and substance use in adolescence” (Masi et al., 2015).

Across different studies, the CBCL-DP profile was linked with comorbidity as well as adult-onset suicidal ideation (Mbekou et al., 2014), depression, anxiety, cluster B personality traits, ADHD, and mood related psychiatric hospitalization (Meyer et al., 2009). Similarly, De Caluwé et al. (2013) found, in a study focused on personality related outcomes of the CBCL-DP, that the profile is predictive for adult-onset DSM-5 borderline and antisocial personality prototypes. Taken together, these studies suggest that the CBCL-severe dysregulated profile (CBCL-DP) could be considered an indicator for youth at risk of developing a bipolar type I disorder and other poor outcomes the same way active smoking and elevated cholesterol could be used as indicators, but not determinants. of adverse health events (Biederman et al., 2009).

CBCL and Autism Spectrum Disorders

Although previous editions of the DSM excluded the comorbid diagnosis of ASD and ADHD, ASD is most often comorbid with ADHD (Lai et al., 2014, 2019). The CBCL has been validated in populations of youth with autism spectrum disorder (ASD; Pandolfi et al., 2012) and has been found to be a very accurate method to assess patients with ASD, ADHD and comorbid ADHD-ASD (Carta et al., 2020). Furthermore, the CBCL was also shown to be a good screening measure for the level of emotional dysregulation in youth with ASD (Joshi et al., 2018) which in turn can help screen for likeliness of comorbidity and dysfunction. It was also shown to be a good predictor of pre-school children at risk of autism in primary care settings (Muratori et al., 2011).

Yoshi et al. (2018) in a controlled study of 123 youth with ASD matched with ADHD and HC control groups of equal number and gender. In their study ASD youth were further stratified depending on their severity of emotional dysregulation (ED): one group without ED, one with moderate ED (≥1SD and <2SD) or with Deficient Emotional Self-Regulation (DESR; ≥2SDs), and one with severe ED (SED). The results showed that the CBCL-ED scores were good indicators for morbidity and dysfunction. The more severely emotionally dysregulated youth were also more likely suffering from a greater burden of psychopathology particularly of the disruptive, depressive, and bipolar spectrum disorders.

Pandolfi et al. (2012) indicate that the most prevalent comorbid disorders present with ASD are depression, anxiety, ADHD, and ODD but notes that these are difficult to detect because of difficulties in social communication, relatedness, awareness, insight, and non-specific symptoms presentations. Carta et al. (2020) were able to show that the CBCL showed promise in assessing internalizing problems in ASD which, by using external informants can help circumvent the phenomenological difficulties of ASD patients’ accurate self-reporting of internal states and problems. Pandolfi et al. (2012) identified two subgroups: one with ASD alone and another with ASD plus emotional and behavioral disorders. Although the CBCL wasn’t specific enough to distinguish between distinct disorders it showed good sensitivity to detect dimensional aspects of disorders (Pandolfi et al., 2012). By combining with other screening methods, the CBCL showed promise in identifying youth with ASD and comorbidities which are associated with poorer functional outcomes (Magyar & Pandolfi, 2017).

Muratory et al. (2011) showed, in a sample of 101 preschoolers, that the CBCL was promising to distinguish between infants at risk of ASD when compared with infants with typical development (TD). The Pervasive Developmental Problem and Withdrawn scales were highly sensitive in discerning between infants with ASD and those showing TD. The specificity was lower when differentiating children with ASD and those with other psychiatric disorders.

CBCL and Conduct Disorders

Conduct disorder (CD) is a youth onset disorder in which rules, basic rights, or norms are repetitively and persistently violated (American Psychiatric Association, 2022) as manifested by aggression toward people and animals, destruction of property, deceitfulness, or theft and serious rules violation. The DSM 5-TR (2022) includes CD specifiers which have prognostic implications: with limited prosocial emotions, lack of remorse, guilt, callous-lack of empathy, unconcerned about performance and shallow-deficient affect. In a research review summarizing several studies, Frick and White (2008) suggested that the callous and unemotional profile was relatively stable across childhood and adolescence.

The symptoms of CD have serious implications for individuals and for society, raising the importance of a reliable screening method.

Yule et al. (2020) showed that the Rule Breaking Behavior Scales were good indicators for Conduct disorders in both males and females in a sample of 674 youth with ADHD. They argue that the Rule Breaking Behavior Scales could be a low-cost screening measure to help early referral, assessment, and treatment of children in need of mental health services and treatment. In a study with 357 subjects with bipolar disorder, Woodward et al. (2023) found that the subjects with concomitant BP and CD had significantly more impaired scores on several dimensions of the CBCL: aggressive behavior, attention problems, rule-breaking behavior, social problem, withdrawn and depressed scales, externalizing problems, and total problem composite scale. The authors also found significantly higher rates of ODD, and substance used disorders notably (Woodward et al., 2023. Using the CBCL and the YSR, the self-report version of the Achenbach, Aebi et al. (2013) found, in sample of 1,031 children and adolescents that oppositional defiant disorder (ODD), presented three distinct dimensions: ODD-irritability, ODD-headstrong, and ODD-hurtful. The ODD-headstrong scale was strongly related with CBCL-Attention problems. The “ODD-hurtful” was not related with delinquent behaviors but was associated negatively with depression and has been identified as a “predictor of treatment resistance in Conduct Disorder in previous studies (Kolko & Pardini, 2010).

Conclusion

Biederman et al. (2021) have provided a strong evidence base that the CBCL can be useful for screening and diagnosing children and adolescents plagued by ADHD, Bipolar Disorder, ASD, and CD. In this article we illustrate that the CBCL can be used to screen and measure ADHD severity as well as to better understand its different subtypes (Faraone et al., 2019; Katsuki et al., 2020; Volk et al., 2006). Despite differing outcomes, studies agree that the CBCL-PBD profile also known as the CBCL-DP is an indicator of an increased risk for very poor outcomes, if not of bipolar disorder itself. The CBCL can be useful in early detection of youth suffering from ASD with or without comorbidities. Finally, although in need of replication, the CBCL-Rule Breaking Behavior Scale appears to be a good indicator for CD (Yule et al., 2020), a serious disorder creating great cost to society.

In the setting of limited mental health resources, this research provides valuable support for a simple and cost-effective screening tool that can guide early identification, triage, and the initiation of concomitant interventions to mitigate the course of psychopathology in youth.

Footnotes

Author’s note

Tribute to Dr. Biederman: Dr Joseph Biederman provided the field of child psychiatry with solid research findings that allow children around the world to benefit from better care. His work has been oriented to improve early detection of psychopathology, access to specialized psychiatric care, and treatment outcomes of a segment of the population that were often overlooked and underserved. He created the field of pediatric psychopharmacology and mentored generations of clinicians and researchers. Among his rich and broad contributions, Dr Biederman explored the possibility to develop objective testing allowing early detection of mental illness among youth with psychopathology.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Pascal Chavannes has no conflicts of interest to declare. Martin Gignac: advisory board for Takeda, Elvium, and Janssen.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Martin Gignac

Author Biographies

Pascal Chavannes is aPsychologist, Psychiatrist, PGY6 in Child and Adolescent Psychiatry.

Martin Gignac is a Forensic Psychiatrist, Child and Adolescent Psychiatrist.

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