An Overview of the Use of the Child Behavior Checklist within Australia An Overview of the Use of the Child Behavior Che...
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An Overview of the Use of the Child Behavior Checklist within Australia An Overview of the Use of the Child Behavior Checklist within Australia provides a comprehensive review of selected Australian studies conducted over the past 20 years that have used the Child Behavior Checklist. The strengths and weaknesses of the CBCL for use in the Australian population are highlighted. In particular, the report discusses: Suitability of the CBCL factor structure and normative data in Australian samples, with reference to large-scale Australian prevalence studies and smaller morbidity studies. Use of the CBCL as a diagnostic tool for Anxiety Disorder, Attention-deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder and Depression. Stability of behavioral and emotional problems within Australian samples. Cross-informant stability between parents, children and teachers of behavioral and emotional problems. The relationship between a range of psychosocial factors and CBCL ratings.
ISBN 0-86431-627-5
9 780864 316271
An Overview of the Use of the Child Behavior Checklist within Australia
Heather Siddons and Sandra Lancaster
An Overview of the Use of the Child Behavior Checklist within Australia
Report prepared by Ms Heather Siddons and Professor Sandra Lancaster, Victoria University
ACER Press
The publisher and authors wish to thank Professor Thomas M. Achenbach for his assistance in preparing this report. This publication has adopted the convention of spelling the words ‘behavior’ and ‘behavioral’ with ‘-or’ not ‘-our’, as is most common in Australia. This decision has been taken for the sake of consistency. Proper names, such as the names of publications, that use the ‘-our’ convention have been printed as published. First published 2004 by ACER Press Australian Council for Educational Research Ltd 19 Prospect Hill Road, Camberwell, Victoria 3124 Copyright © 2004 Australian Council for Educational Research All rights reserved. Except under the conditions described in the Copyright Act 1968 of Australia and subsequent amendments, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical. Photocopying, recording or otherwise, without the written permission of the publishers. National Library of Australia Cataloguing-in-Publication data: Siddons, Heather. An overview of the use of the child behavior checklist within Australia: report. Bibliography. ISBN 0 86431 627 5. 1. Child Behavior Checklist - Australia. 2. Behavioral assessment of children - Australia. 3. Child psychology Research - Australia. I. Lancaster, Sandra. II. Title. 155.4 Visit our website: www.acerpress.com.au
TABLE OF CONTENTS 1
THE CHILD BEHAVIOR CHECKLIST (CBCL) AND RELATED FORMS
1
1.1 The CBCL and Related Forms
1
1.2
CBCL, YSR and TRF Scales 1.2.1 Social Competence Scales 1.2.2 Problems at Various Levels
1 1 1
2
FACTOR STRUCTURE OF THE CBCL
4
2.1
Cross-Cultural Generalisability of the 8-Factor Cross Informant Model
4
2.2
Conclusions
5
3
USE OF CBCL ACROSS AUSTRALIA
6
3.1 The Western Australian Child Health Survey (WACHS) 3.1.1 Morbidity Rates
6 6
3.2 The National Survey of Mental Health and Wellbeing: The Child and Adolescent Component
8
3.3 The CBCL in a New South Wales Sample 3.3.1 Sample Description 3.3.2 Problem Behaviors 3.3.3 Cutoff Scores
9 9 9 10
3.4 Problems and Competencies Reported by Parents of Children in New South Wales and America 10 3.4.1 Problem Items 10 3.4.2 Competence Scales 11 3.5 The CBCL in a Melbourne Urban Sample 3.5.1 Sample Description 3.5.2 Level of problems 3.5.3 Comparisons between Sydney and American Data
11 11 11 12
3.6
Conclusions
12
4
MORBIDITY STUDIES IN SELECT POPULATIONS
14
4.1 Immigrant Children and Adolescents
14 i
4.2
Clinical Populations 4.2.1 A Melbourne Clinical Sample 4.2.2 A Sydney Clinical Sample 4.2.3 Western Australian Clinic Samples
15 15 15 15
4.3
Conclusions
16
5
DIAGNOSTIC UTILITY
17
5.1
Behavioral and Emotional Problems 5.1.1 A Western Australian Sample 5.1.2 A Melbourne Sample 5.1.3 A Brisbane Sample
17 17 17 18
5.2 Anxiety Disorders 5.2.1 Identification of Anxiety Disorders 5.2.2 Measure of Anxiety Severity
18 18 18
5.3 Attention Deficit Hyperactivity Disorder 5.3.1 Diagnostic Utility 5.3.2 CBCL Scores Across DSM-IV ADHD Subtypes
20 20 20
5.4 Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) 5.4.1 Identification of an ODD and CD Factor 5.4.2 Symptom Level Among Children with ODD and CD
21 21 21
5.5 Depression 5.5.1 Development of a CBCL Depression Scale 5.5.2 Development of a YSR and CBCL Scale Equivalent to the CDI 5.5.3 Diagnostic Utility of Proposed Depression Scales
22 22 22 23
5.6
Comorbidity
24
5.7
Conclusions
25
6
STABILITY OF BEHAVIORAL AND EMOTIONAL PROBLEMS
27
6.1
WACHS Pilot Study
27
6.2
The Port Pirie Cohort Study
27
6.3
Conclusions
28
7
CROSS INFORMANT STABILITY
29
ii
7.1
South Australian Community and Clinic Samples 7.1.1 Mean Level of Problems in a Community Sample 7.1.2 Clinical Caseness 7.1.3 Mean Levels of Problems in Community and Clinic Samples
29 29 30 30
7.2
Victorian Clinical Sample
30
7.3
A Sydney Clinical Sample
31
7.4
Conclusions
31
8
BIOPSYCHOSOCIAL FACTORS AND CBCL REPORTS
33
8.1 School related problems 8.1.1 Academic problems 8.1.2 Bullying
33 33 33
8.2 Parental Mental Health
33
8.3 Child Gender
34
8.4 Demographic factors
35
8.5
Conclusions
36
9
FINAL REMARKS
37
10
REFERENCES
38
11
APPENDICES
42
11.1 Appendix 1: Use of CBCL Across Australia - Associated Tables
42
11.2 Appendix 2: Morbidity Studies in Select Populations – Associated Tables
51
11.3 Appendix 3: Diagnostic Utility – Associated Tables
55
11.4 Appendix 4: Stability of Behavioral and Emotional Problems – Associated Tables
63
11.5 Appendix 5: Cross Informant Stability – Associated Tables
65
11.6 Appendix 6: Biopsychosocial factors and CBCL reports - Associated Tables
69
11.7 Appendix 7: Bibliography of Published Australian Studies Using the Achenbach System of Empirically Based Assessment (ASEBA) 70 11.7.1 Diagnoses 70 11.7.2 Normative and Prevalence Studies 70 iii
11.7.3 Oppositional Defiance and Conduct Problems 11.7.4 Attention Problems and Hyperactivity 11.7.5 Depression 11.7.6 Delinquency and homelessness 11.7.7 Assessment Issues 11.7.8 Neuropsychological Assessment 11.7.9 Anxiety 11.7.10 Psychosocial Factors 11.7.11 Physical Illness 11.7.12 Sexual Abuse 11.7.13 Other
iv
71 72 73 74 74 75 76 77 78 80 80
1
The Child Behavior Checklist (CBCL) and Related Forms
1.1
The CBCL and Related Forms
The CBCL is a standardised questionnaire, completed by parents or primary caregiver, which provides a measure of behavioral and emotional functioning and social competence of children and adolescents. The CBCL has two sections, social competence and problem behaviors. The original normative data is based on a United States sample of 4,455 referred and non-referred children aged 4- to 16-years for the CBCL problem behaviors and a sample of 2,368 non-referred children aged 4- to 16-years for the competence scales (Achenbach & Edelbrock, 1983). Some revision to the CBCL factors was made and revised normative data for children aged 4- to 18-years were released in 1991 (Achenbach, 1991). An extensive review of the American normative data is provided in the CBCL manual (Achenbach, 1991; Achenbach & Edelbrock, 1983). Recently, the CBCL was updated “to incorporate new normative data, include new DSM-oriented scales, and to complement the new preschool forms” (Achenbach, 2002). The new version of the CBCL is suitable for children aged 6- to 18-years and the preschool version is appropriate for children aged 1½- to 5-years. The YSR and TRF are essentially parallel forms of the CBCL to be completed by the young person and teacher, respectively. The original versions of the YSR and TRF are normed for ages 11- to 18-years and 5- to 18-years respectively. The 2001 versions of the YSR and TRF are normed for ages 5- to 18-years and 6- to 18-years, respectively. The original versions of the CBCL, TRF and YSR contain 89 common items, thus allowing for cross-informant comparisons. Note, the 2001 editions have 93 items in common. The majority of research summarised in this report utilised the 1983 form or 1991 forms.
1.2
CBCL, YSR and TRF Scales
1.2.1
Social Competence Scales
This section contains 20 items and is designed to measure children’s positive adaptive functioning. Responses provide measures on 3 subscales: Activities: The amount and quality of participation in sports, hobbies, games, activities, jobs and chores Social: Friendships, how well child gets along with others, behaves, and plays and works alone School: Academic performance, special class, repeated grade, school problems 1.2.2
Problems at Various Levels
The CBCL contains 118 items describing a broad range of problems. There are also two items on which informants may provide additional information through open-ended responses. Responses are used to provide a measure of behavioral and emotional functioning on four different levels: Total problem score; Broad-band scores; Syndrome scale scores; Item scores. 1.2.2.1
Item Scores
The respondent is required to indicate how well each item describes their child’s behavior within the past 6-months, using a three-point scale (0 = not true, 1 = somewhat or sometimes true, 2 = very true or often true).
1
1.2.2.2
Syndrome Scale Scores
Factor analysis, conducted separately for each sex/age groups, identified the 8 syndrome scales, which are computed by summing responses to the relevant individual items. The initial factor analysis utilised varimax rotation, which means that the rotated factors are uncorrelated. There are 8 comparable syndrome scales that can be computed from the CBCL, TRF and YSR (see Table 1). Table 1. CBCL and Cross Informant Scales 1991 Version CBCL/4-18
Cross informant scales
Behavior scales: Withdrawn Somatic Complaints Anxious/Depressed Social Problems Thought Problems Attention Problems Delinquent Behavior Aggressive Behavior Sex Problems (age 4-11) Externalising problems Internalising problems Total problems scale Competence scales: Activities Social School Total competence
Behavior scales: Withdrawn Somatic Complaints Anxious/Depressed Social Problems Thought Problems Attention Problems Delinquent Behavior Aggressive Behavior Externalising problems Internalising problems Total problems scale Competence scales: Activities Social Total competence
2002 Version CBCL/1½-5 (caregiver/teacher form) Behavior scales: Withdrawn Somatic Complaints Anxious/Depressed Emotionally Reactive Aggressive Behavior Attention Problems Sleep problems Externalising problems Internalising problems Total problems scale
Competence scales: Language Development Survey
DSM-IV oriented scales: Affective Problems Anxiety Problems Pervasive Developmental Problems Attention Deficit/Hyperactivity Problems Oppositional Defiant Problems
1.2.2.3
CBCL/6-18 Behavior scales: Withdrawn/Depressed Somatic Complaints Anxious/Depressed Social Problems Thought Problems Attention Problems; Rule-Breaking Behavior Aggressive Behavior Externalising problems Internalising problems Total problems scale Competence scales: Activities Social School Total competence DSM-IV oriented scales: Affective Problems Anxiety Problems Somatic Problems Attention Deficit/Hyperactivity Problems Oppositional Defiant Problems Conduct Problems
Broad Band Scales
A second order principal factor analysis with varimax rotation of the correlations among the scale scores, conducted separately for each sex/age group, identified two broad band scales: Internalising problems and Externalising problems. The internalising factor reflects problems of withdrawal, somatic complaints, and anxiety/depression, whilst the externalising factor reflects delinquent and aggressive behavior. 2
The attention problems syndrome scale loaded highly on the Externalising factor (0.618). However, the loading was considered significantly lower than the aggressive and delinquent behavior loadings and therefore deemed inappropriate to include with the Externalising grouping. Neither the Social Problems nor the Thought Problems scales had consistently high loadings on either the Internalising or Externalising factor.
3
2
Factor Structure of the CBCL
This section reports research findings regarding the validity of using the CBCL factor structure with Australian children. Research examining the identification of new factors for oppositional defiant disorder, conduct disorder and depression are discussed in Section 5.
2.1
Cross-Cultural Generalisability of the 8-Factor Cross Informant Model
A recent study examined the cross-cultural generalisability of the 1991 8-factor cross-informant model of the CBCL for clinically referred children and adolescents from Australia, America and Holland (2000). Thus, confirmatory factor analyses were performed using only the 85 cross-informant items within each sample. The Australian sample comprised 2237 children (1523 boys, 714 girls) who had attended a mental health service within New South Wales during the period 1983-1997. Approximately 59% of the boys were aged less than 12-years, whilst the remaining boys were 12-years or older. Approximately 37% of the girls were aged less than 12-years, with the remainder of the girls 12-years or older. Ninety-percent of the informants were mothers, 5% fathers, 3% others, 2% unknown. The majority of participants were of Caucasian background. The American samples used were the CBCL 1991 clinical sample (n = 2110) (Achenbach, 1991) and a sample of 631 children and adolescents aged 8- to 18-years with severe emotional problems who had participated in a national treatment study (Dedrick, Greenbaum, Friedman, Wetherington, & Knoff, 1997, cited in Heubeck, 2000 #111). The Dutch sample comprised 2335 children and adolescents aged 4- to 18years recruited through mental health clinics. Heubeck (2000) utilised confirmatory factor analyses on the 1-factor and 8-factor models developed by Achenbach (1991). The analyses yielded important results. There was good support for a 1-factor model within the American, Dutch and Australian samples. Thus, overall the CBCL seemingly represents a basic psychopathology factor. The 8-factor model developed by Achenbach utilised a varimax rotation, which statistically ‘forces’ the factors to be independent. Using a varimax rotation, Heubeck’s results indicated that the uncorrelated 8factors model does not fit the Australian, American and Dutch data. However, Heubeck demonstrated that use of an alternative rotation method, which allows the factors to be correlated, results in an 8-factor model providing a better fit of the Australian, American and Dutch data compared to the 1-factor model. The confirmatory factor analyses (with correlated factors permitted) revealed that approximately 90% of the items loaded on the factors that they are purported to represent. Best convergent validity was shown for items measuring somatic complaints, anxious/depressed and aggressive syndromes, with the majority of items demonstrating a factor loading of at least 0.30 on the factors which they were assigned to by Achenbach (1991). The withdrawn, thought problems and delinquent syndromes also demonstrated good convergent validity using the Australian, Dutch and American data, though the confirmatory factor analysis identified additional items on each of these factors. Nevertheless, Heubeck advised that the withdrawn, somatic complaints, anxious/depressed, thought problems, delinquent, and aggressive behavior syndromes may be “used with some confidence” in Australia (p, 445). In contrast, relatively poor support was found for the CBCL factors alleged to measure attention and social problems (Heubeck, 2000). Using the Australian data, 4 of the items purported by Achenbach (1991) to measure attention received loadings of less than 0.30. In terms of attention, only 3 (8. 4
concentrate; 10. sit still; and, 41. impulsive) of the 14 items loaded on the same factor across the three countries. Heubeck (2000) suggested that the attention factor proposed by Achenbach may benefit from substantial revision, perhaps incorporating recent advances which have suggested that ADHD may be better defined along two dimensions, inattention and overactivity. Such revisions have been made in the 2001 revision of the correlated 8-factor model (Achenbach & Rescorla, 2001), which provides Inattention and Hyperactivity-Impulsivity subscales for scoring the TRF. The confirmatory factor analysis conducted by Heubeck (2000) provided very poor support for the social problems factor and Heubeck argued that the “social problems factor needs a major reconceptualisation” (p. 456). Heubeck’s analysis identified only 3 items purported to measure social problems (25. not get along with other kids, 38. teased, and 48. not liked) that had an adequate loading on the same factor using the Australian, American and Dutch samples. From an additional exploratory factor analysis, Heubeck identified a number of extra items that loaded on the social problems factor. The inclusion of these items on the social problems factors seemed to change the meaning of the factor, so that perhaps it better describes a child who may be “rejected, but who is mean, destructive, antisocial, and probably a bully” (p. 456), rather than a child who may be “immature and clumsy and who does not get along well with peers” (p. 456). Heubeck discussed the issue of items loading on more than one factor. The confirmatory factor analyses demonstrated that none of the five items purported by Achenbach to load on more than one factor actually did so, while items 45 (nervous) and 103 (sad) received substantial loadings on more than one factor using either the American, Dutch or Australian data. A number of other cross-factor loadings were also identified by Heubeck who advised that a revised version of the CBCL should incorporate such cross loadings. The revised correlated 8-factor model published in 2001 along with other changes, eliminated cross-loading items (Achenbach & Rescorla, 2001).
2.2
Conclusions
There is good support for the use of the CBCL 1-factor model (i.e. total behavior score) and 6 of the 8 CBCL syndromes (withdrawn, somatic complaints, anxious/depressed, thought problems, delinquent, and aggressive behavior) within clinic samples in New South Wales. Conversely, less confidence may be placed in use of the attention and social problems syndrome scales. However in terms of overall validity, the study by Heubeck (2000) is somewhat limited, as the Australian sample were drawn from mental health clinics within New South Wales and may not be representative of children from a non-clinical population and/ or children in other Australian states. Thus, the CBCL factor structure requires further validation to improve confidence that it is applicable to all Australian children.
5
3
Use of CBCL Across Australia
This section provides a summary of studies that have used the CBCL to assess morbidity of mental health problems among young Australians and/or the appropriateness of using the American norms with Australian populations. (Achenbach, Hensley, Phares, & Grayson, 1990; Bond, Nolan, Adler, & Robertson, 1994; Hensley, 1988).
3.1
The Western Australian Child Health Survey (WACHS)
The Western Australian Child Health Survey (WACHS) is a comprehensive study of the prevalence of mental health problems among children aged 4- to 16-years living in Western Australia (Garton, Zubrick, & Silburn, 1995). A range of measures was used to screen for mental health morbidity, including the CBCL and parallel forms (YSR, TRF). 3.1.1 3.1.1.1
Morbidity Rates Pilot Survey
A pilot study was conducted in 1992 on a random sample of 260 Perth metropolitan area households, of which 189 agreed to participate (Garton et al., 1995). Each household was provided with a CBCL, YSR and TRF to be completed and returned by post. The 189 households provided data for 321 young people (163 male, 158 female). Of the 189 households who agreed to participate, response rates were as follows: 96.3% CBCL, 94.5% YSR (12- to 14-years), and 93.0% (YSR 15- to 16-years). Morbidity of mental health problems was determined by including all children who scored greater than the 98th percentile (T score 70 or more) for at least one CBCL syndrome. Results indicated that 11.2% (n=36) of the pilot sample had deviant scores on at least one mental health syndrome. The prevalence of elevated scores on one or more syndromes increased to 19.3% if a cutoff at the 95th percentile (T score of 67 or more) was used. The mean CBCL raw scores and T scores by gender and age of the sample used in the WACHS pilot study revealed slightly, though not markedly, lower levels of total behavioral and emotional problems compared to the US 1991 norms (Table 2) (Garton et al., 1995). Table 2. Mean CBCL Raw and T Scores, by Gender and Age for the WACHS Pilot Sample (n = 321) and US Norms (Taken from Garton (1995)) Boys Girls US WACHS US WACHS US WACHS WACHS US 4-11 4-11yrs 4-11 yrs 12-16yrs 12-18 yrs 4-11yrs 12-16yrs 12-18 yrs yrs Raw Score Mean 22.6 24.3 21.3 22.5 17.9 23.1 17.7 22.0 SD 17.2 15.6 15.3 17.0 16.2 15.5 14.6 17.7 T Score Mean 48.6 50.1 49.5 50.0 45.5 50.1 46.9 50.0 SD 10.8 9.9 9.8 10.0 11.7 9.9 10.9 10.2
6
3.1.1.2
Main WACHS Survey
The main WACHS survey was conducted in 1993 and estimated morbidity rates of behavioral and emotional problems based on data on 2737 children aged 4- to 16-years living in Western Australia. Analyses yielded an overall prevalence of 17.7% for mental health morbidity. This figure was based on a participant being identified as a case by a T score equal to or greater than 60 on the CBCL and/or TRF. Prevalence of mental health morbidity for the entire WACHS sample is reported in Table 3. A greater proportion of boys than girls (20% versus 15.4%) were identified as having mental health problems (Zubrick et al., 1995). Table 3. Prevalence (%) of Mental Health Morbidity Within and Across Informants (Taken from Zubrick et al. (1997)) Age group Source
4-11 years
12-16 years
All children
Parent report
10.0
11.3
10.4
Teacher report
11.4
16.4
13.3
Not collected
35.7
24.6
Parent, teacher & youth reports combined
16.1
35.3
23.1
Parent & teacher reports combined
16.1
20.3
17.7
Youth report
Morbidity on individual syndromes was defined by having a T score on the CBCL and/or TRF equal to or greater than 67. Nearly 28% of children and adolescents were identified as being in the clinical range for at least one syndrome, 15.9% of whom were also identified as having overall behavioral/emotional problems. The morbidity rates for each CBCL syndrome are reported in Table 4. Table 4. Pecentage of Children With Mental Health Problems: Type of Problem, According to CBCL/TRF Reports (Taken from Zubrick (1995)) Sex Age group (years) Males
Females
4-11
12-16
All children
Delinquent problems
10.5
8.5
10.1
8.6
9.5
Thought problems
9.6
7.6
7.5
10.4
8.6
Attention problems
6.6
5.9
5.5
7.6
6.3
Social problems
7.0
4.7
5.7
6.0
5.9
Somatic complaints
7.0
3.1
4.7
5.6
5.0
Aggressive behavior
4.2
3.2
3.1
4.6
3.7
Anxiety/depression
4.7
2.6
3.0
4.8
3.6
Withdrawn
3.1
2.1
2.5
2.7
2.6
7
Adolescent suicidal ideation and deliberate self-harm were assessed via two items on the YSR. The WACHS report indicated that an estimated 15% of students had experienced suicidal ideation (22% adolescents aged 15-16 years and 12% adolescents aged 12-14 years) (Zubrick et al., 1995; Zubrick et al., 1997). A prevalence of 7.5% was reported for deliberate self-harm (8.6% adolescents aged 15-16 years and 6.8% adolescents aged 12-14 years). This figure received some validation from the results of a nation-wide survey conducted by the Centre for Diseases Control in USA, which reported a prevalence of 8.3 for deliberate self-harm among 11,000 high school students (Zubrick et al., 1997).
3.2
The National Survey of Mental Health and Wellbeing: The Child and Adolescent Component
One of the aims of the child and adolescent component of the National Survey of Mental Health and Wellbeing was to estimate the proportion of Australian children and adolescents with specific mental health disorders (Sawyer et al., 2000). The final sample surveyed was representative of Australian children and adolescents aged 4- to 17-years. Of those households identified as a having an eligible child, 86% agreed to participate, giving a response rate of 70%. Analyses revealed limited response biases. The CBCL was completed for 4083 children and adolescents (2082 male, 2001 female). The distributions of CBCL and YSR respective mean scores were consistent with the results reported in the WACHS (Sawyer et al., 2000). As in the WACHS, prevalence estimates of mental health problems were calculated using the cut-offs recommended by Achenbach (1991). Prevalence estimates (Sawyer et al., 2001) are reported in Table 5. Using the CBCL cutoffs, 573 children were identified as having a clinically significant mental health problem, whilst a further 500 were classified as having ‘sub threshold’ problems (CBCL T score 54-59). Table 5. Prevalence (%) of Mental Health Problems in 4-17-Year-Old Children (Taken from (Sawyer et al., 2001) Total % (n = 4083)
Males (n = 2082)
Females (n = 2001)
Total problems
14.1 (521 886)*
14.4
13.9
Externalising problems
12.9 (475 748)*
12.9
12.9
Internalising problems
12.8 (473 989)*
14.5
11.1
Somatic complaints
7.3
8.4
6.1
Delinquent behavior
7.1
7.1
7.1
Attention problems
6.1
6.5
5.6
Aggressive behavior
5.2
5.6
4.8
Social problems
4.6
5.6
3.6
Withdrawn
4.3
5.2
3.4
Anxious/depressed
3.5
3.9
3.2
Thought problems
3.1
3.3
2.8
CBCL Scale Broad band scales
Syndrome scales
8
*Population estimate The slightly lower prevalence estimate of 14% compared to the approximate WACHS 18% is accounted for by the fact that the WACHS prevalence estimate was based on combined parent and teacher reports, whereas the prevalence estimate of the National Survey was based solely on parent report. Comparison of parent and adolescent reported problems across surveys yielded very similar prevalence estimates (Sawyer et al., 2001). Correlations between informants were significant for clinical and sub-threshold caseness, and a range of other problems, after controlling for demographic factors (Sawyer et al., 2001). Some validity of the CBCL findings was obtained. Children with CBCL clinically significant problems were also rated by parents to have poorer self-esteem, more emotional and behavioral problems, poorer general health and greater pain and discomfort, as measured by the Child Health Questionnaire (CHQ), than children with sub-threshold problems. In turn, children with sub-threshold problems were reported to have more problems on the CHQ than non-clinical children. Children in the clinical and sub-threshold groups were also more likely to report suicidal ideation and behavior, and risk-taking behavior compared to the non-clinical group, even after controlling for operational confounds.
3.3
The CBCL in a New South Wales Sample
3.3.1
Sample Description
In an earlier study, Hensley (1988) used the CBCL with an Australian sample, comparable to the American 1981 normative sample with respect to age, gender and method of sample recruitment. The final sample for the study comprised 1300 children aged 4 through 16 years, with 50 children within each yearly age/sex group. Seventy-eight children who had received some form of psychological evaluation or treatment by a psychologist, psychiatrist or school counselor were excluded from the normative sample of 1300 non-referred children. In contrast to the American 1981 normative sample, the Australian sample was entirely metropolitan and urban (within Sydney, New South Wales). Efforts were made to replicate the American method of data collection. Ethnic variation within the Australian sample was comparable to the 1981 Census for the Sydney population, though there was a greater representation of immigrant families compared to the American normative sample. The non-inclusion of rural families and a larger proportion of immigrant families in the Australian sample may marginally limit the value of making comparisons to the American sample. The sample cannot be assumed to represent all areas of Australia (Achenbach et al., 1990) or the current Australian population . The proportion of the Australian sample within each socio-economic category generally fell between the proportion of the American clinical and the American normal samples. However, a significantly greater proportion of the Australian sample than the American normal sample fell within the unskilled category (which included the unemployed, single mothers and invalid pensioners). 3.3.2
Problem Behaviors
Results indicated that morbidity of total behavior problem, internalising and externalising problems for each age by gender group was significantly greater among the Australian sample compared to the American sample. Though somewhat less striking, there was a trend for the Australian sample to have poorer social competence, with the exception of activities, where 4- to 5-year old Australian boys and 6to 11-year old Australian girls were involved in more activities than their American counterparts. 9
Tables 1 to 6 in Appendix 1 display the mean raw scores of the problem behavior broad-band scales, total behavior problem score, social competence subscales and total scores, and t-values for contrasted pairs of means. Using a significance level of 0.01, t-values greater than 2.57 indicate significant differences between the Australian and American mean scores. It is unclear why the Australian children were rated to have significantly higher levels of behavior problems and poorer social competence. Subsequent analyses suggest that the differences could not be accounted for by disparate distributions of socioeconomic status between the countries. A more plausible explanation is the geographic location. Both the Australian and American samples were recruited from metropolitan and urban areas. However, a proportion of the American sample was also recruited from semi rural environments. International and Australian prevalence studies have reported higher incidence of psychiatric problems in urban and metropolitan areas (Connell, Irvine, & Rodney, 1982 and Rutter, 1975 #158, cited in Hensley, 1988 #6). Nevertheless, a study conducted by Bond et al. (1994) (described later) showed Sydney children to have higher levels of problem behaviors than Melbourne children living in urban metropolitan regions. 3.3.3
Cutoff Scores
Hensely (1988) also reported adjusted clinical cut-offs at the 90th percentile using the Australian data (Appendix 1, Tables 7 to 17) for the total and broad-band scales and competence scale. Similarly adjusted cutoffs were suggested for the syndrome subscales. However, Hensley urged that the modified cutoff points could not be used with confidence until a large clinically based Australian study is conducted.
3.4
Problems and Competencies Reported by Parents of Children in New South Wales and America
In a subsequent study, Achenbach, Hensley, Phares and Grayson (1990) examined item responses to compare problems and competencies reported for the sample of 1300 non-referred children from Sydney and the American non-referred normative sample (n = 1300). 3.4.1
Problem Items
A series of ANCOVA’s (SES as the covariate) were computed to examine differences between the Australian and American samples on every problem item and the total problem behavior score. As high statistical power makes it possible to detect very small effects, the authors utilised Cohen’s criteria for judging the magnitude of each effect, rather than merely statistical significance. An effect size accounting for 1-5.9% of the variance is considered small. An effect size accounting for 6.0-13.8% of the variance is considered medium. An effect size accounting for >13.8% of the variance is considered large. The Australian sample showed higher scores than the American sample on 80 specific items, the two open-ended items and the total behavior problem score. These differences were generally applicable across age and gender however the pattern of sex differences among the Australian sample was similar to the pattern of sex differences in the American sample. Also, 54 of the differences in problems endorsed were judged as having small nationality effects, whilst 23 accounted for less than 1% of the variance. Only one item (96: Thinks about sex too much) was identified as having a large nationality effect, with the item being endorsed by 39% of the Australian parents versus 2% of the American sample. Four items 10
and the total behavior problem scores showed medium nationality effects (see Table 18, Appendix 1). Nationality interacted with age for item 60 (Plays with sex parts too much), whereby the difference between the Sydney and American scores was less at ages 10- to 11-years and 16-years. 3.4.2
Competence Scales
The American children were rated as having significantly better social competence scores for 10 of the 20 items, and the Social Scale and Total Competence Scores (see Table 19, Appendix 1). Importantly, the majority of differences between the Sydney and American samples on the competency items yields a small effect size or accounted for less than 1% of the variance. Medium difference effects were demonstrated for two items: American parents reported their children to have significantly more contact with friends and to be involved in more sports; and Sydney parents reported their children as having significantly more friends than American children. Exclusion of the children who were rated within the clinically significant range on the Total Behavior Problem Score (29% Australian, 10% American) did not significantly alter the nationality difference in the number of problem behaviors. Sydney parents endorsed a significantly greater number of problem items than American parents, even when coding the items responses dichotomously. Moreover, Sydney parents endorsed a significantly greater number of items as occurring frequently than did American parents. The items endorsed by Sydney and American parents were not specific to either internalising or externalising problems.
3.5
The CBCL in a Melbourne Urban Sample
3.5.1
Sample Description
Bond et al. (1994) conducted a study to compare CBCL scores for a sample of non-referred Melbourne children with the revised 1991 American normative data and the New South Wales data (Hensley, 1988). The study was part of a larger study on asthma prevalence and morbidity. All children attending Years 2, 7 and 12 (7-, 12-, and 15-year-olds, respectively) in a random selection of Government, Catholic and independent schools in metropolitan Melbourne and surrounding areas were invited to participate. In total, 1,774 households completed the CBCL (46% response rate). The sample was reduced to reflect the prevalence of asthma, leaving 1051 children of whom 228 were asthmatic. The final sample, after excluding children who had been seen by a psychologist or psychiatrist, consisted of 1009 children (564 Year 2, 250 Year 7 and 195 Year 10; 63% boys). It is important to acknowledge that the study conducted by Bond et al. (1994) did not permit conclusions about prevalence rates because of the high attrition rate. Comparisons between the Melbourne sample and the Sydney and American samples is somewhat limited by the lack of representation of children at each age level. 3.5.2
Level of problems
Analyses of the Melbourne sample indicated that overall girls were reported to have higher levels of internalising problems, whilst boys had higher levels of externalising problems. The 7-year-olds were rated to have greater levels of total behavior problems and externalising problems than older children. The 12-year-olds were also rated higher than 7-year-olds on the activities and social subscale and the overall competence score. The 12-year olds were also rated as having better social competence, but also 11
had higher levels of externalising problems than the 15-year-olds. Mean scores are presented in Table 20, Appendix 1. 3.5.3
Comparisons between Sydney and American Data
The data collected by Bond et al. (1994) was compared to the 1991 revised American norms and to the Sydney data (re-scored using the revised scales). Means are presented in Appendix 1, Tables 21 and 22. The children in Years 7 and 10 were combined and overall, Sydney children were rated as having more behavior problems than Melbourne children, even after controlling for differences in socio-economic status. The differences between the Sydney and Melbourne samples were larger than the differences between the American and Melbourne samples on the total problem, internalising and externalising scores. Comparable to the Sydney and American item differences, a significant difference in mean item ratings between the Sydney and Melbourne data was found for 77 items. The Melbourne sample scored significantly higher on 8 items only, many of which referred to somatic problems. This may be reflective of the deliberate inclusion of children with asthma, whose parents may be more sensitive and likely to report physical problems. In particular, the Sydney sample was identified as scoring significantly higher than the Melbourne sample on the following items: 113. Other problems; 83. Stores up unneeded things; 96. Thinks about sex too much; 112. Worries; 86. Stubborn; 38. Is teased; 45. Nervous; 109. Whining; 93. Talks too much; and, 27. Jealous. All of these items (excluding item 27 ‘jealous’) were also identified by Hensely (1988) as being more problematic for the Sydney children compared to the American children. National differences emerged for the competence scales, where both Sydney and Melbourne children were reported to be more involved in activities and less involved in social organisations than American children.
3.6
Conclusions
The CBCL has been used to provide morbidity estimates among non-referred Australian children and adolescents. Reported estimates (using a criterion of T score ≥ 60 for total problem scale) have ranged from 10.0 to 20.3, depending on the whether the informant was parent, teacher, or combination. Somewhat higher morbidity estimates (24.6 to 35.7) have been reported using the YSR. The WACH also estimated 28% morbidity on at least one syndrome. This estimate was based on a T score ≥ 67 on either the CBCL or TRF. The morbidity estimates are likely to be over-inclusive, as Achenbach’s cutoffs for borderline levels of clinical problems were used. The WACHS indicated that 15% of children and adolescents endorsed the item assessing suicidal ideation and 7.5% endorsed the item assessing deliberate self-harm. These rates were higher than those indicated in parent and teacher reports, highlighting the importance of asking the young person about their wellbeing. Research has also shown the potential use of the CBCL to estimate odds of having particular problems, such as academic problems, bullying and familial problems. The similar distribution of problems across the WACHS and Child and Adolescent Component of the National Survey of Mental Health and Well-Being provide support for the reliability of the CBCL in Australian populations. Research using the original CBCL factor structure (Achenbach & Edelbrock, 1983) suggests a higher mean level of parent-reported behavioral and emotional problems and poorer social competence among children in New South Wales than America, though the patterns of sex differences were similar. Thus, 12
use of American norms may identify a greater number of Australian children as having clinically significant problems. Adjusted norms have been proposed using a non-clinical sample drawn from New South Wales. However, this may not be warranted as the size of cross-cultural differences was generally of small effect. In contrast, there is minimal evidence indicative of significant differences in parent reported problem behaviors between the Melbourne and Western Australian non-clinical samples and the American nonclinical normative sample, using the revised CBCL scales (Achenbach, 1991). However, as with the American sample, Melbourne children were generally shown to have fewer behavioral and emotional problems than children in New South Wales. Differences in methodology, sample demographics, and duration of studies mean that caution must be exerted when using either the American or suggested Australian norms for Australian samples. The study using a New South Wales sample utilised the original version of the CBCL (Achenbach & Edelbrock, 1983), whilst the Melbourne study and the WACHS used the 1991 revisions (Achenbach, 1991). However, it is highly unlikely that these changes would have altered the main finding that morbidity rates for problem behaviors and poor social competence are significantly higher among Sydney children than the American normative sample. As stated by Bond et al. (1994), despite the average increase of 3 points for the problems scores using the 1991 revision, the data presented by Hensley remains significantly higher than the American norms. Since these studies were conducted, the CBCL has undergone yet further revisions. Clearly, research is required to examine the utility of the most recent American norms within Australia and also to examine the utility of American YSR and TRF norms within Australia.
13
4
Morbidity Studies in Select Populations
The previous section provided an overview of studies that used the CBCL to estimate morbidity of mental health problems amongst Australian children and adolescents. This section summarises some research that used the CBCL to estimate morbidity rates using samples of Australian immigrants and children attending psychiatric services.
4.1
Immigrant Children and Adolescents
The level of behavioral and emotional problems and competencies among Australian immigrant children has been examined using the CBCL and YSR (Davies & McKelvey, 1998; Goldney, Donald, Sawyer, Kosky, & Priest, 1996). The study conducted by Goldney and McKelvey (Davies & McKelvey, 1998; Goldney et al., 1996) utilised a sample of 209 adolescents aged 12- to 16-years living in Perth and attending mainstream schools. An additional 53 adolescents were recruited though an Intensive Language Centre in Perth. In total, the CBCL was completed for 255 adolescents. The YSR was also available for 211 participants. Ninety-four (36.9%) participants were born overseas. The mean age of the immigrant adolescents was 13.9 years, whilst the mean age of the non-immigrant adolescents was 14.13 years. According to parent reports immigrant adolescents had fewer externalising problems than the nonimmigrant adolescents. In contrast, parent reports indicated that immigrant adolescents had fewer social competencies than non-immigrant adolescents. Similarly, self-reports (using YSR) completed by immigrant adolescents indicated fewer externalising and overall problems, but also fewer social competencies than non-immigrant adolescents. There was no reported difference in levels of internalising problems between immigrant and non-immigrant adolescents. Immigration status remained predictive of YSR (but not CBCL) externalising and competencies scores, even after controlling for SES, family composition, age, gender, parental immigration status, primary language and school setting. Goldney, Donald, Sawyer, et al. (1996) compared the levels of parent and self-reported behavioral and emotional problems of Indonesian adoptees (23 males, 11 females) with a mental health clinic population (68 males, 32 females) and a community sample of 100 two-parent families. Within the community sample the YSR report was completed by 116 males and 117 females, and the CBCL was completed for 121 males and 120 females. The average age at adoption for the Indonesian sample was 1 year 5 months. All children were aged 14- to 15-years at the time of participation in the study. Results showed no significant differences in levels of behavioral and emotional problems between the community and adoptee samples, according to both parent and self-report. Overall, both community and adoptee samples were shown to have significantly fewer behavioral and emotional problems than the clinic sample (see Appendix 2, Tables 1 to 4). The adoption sample did not differ from the clinic sample for female self-report of externalising problems, thought disorder and aggressive behavior, and parent report for females on the schizoid and delinquent subscales. The lack of significant differences was most likely due to limited power related to the very small sample size of adopted females. Consistent with other studies, children reported greater levels of problems than did parents.
14
4.2
Clinical Populations
4.2.1
A Melbourne Clinical Sample
4.2.1.1
Clinical Cutoff
The applicability of the US normative CBCL cut-off scores for the classification of behavior disorders was assessed using a Melbourne sample of 1342 children referred to a mental health outpatient service between July 1991 and October 1992 (Nolan et al., 1996). A Melbourne community sample (described previously) was used as a comparison sample (Bond et al., 1994). According to Achenbach (1991), on the behavior scales, a T score less than 60 is classified as non-clinical, a T score of 60-63 is borderlineclinical, and a T score of >63 is clinical. The mean T scores for referred children were above the clinical range across age and gender (see Table 5, Appendix 2). On the competence scales, a T score below 30 is considered clinical (and below 33 is considered borderline-clinical), as low competence scores are clinically important. Compared to the American clinical data, a greater proportion of clinically referred Melbourne children scored above the CBCL clinical cutoff (T score 60+) for the total behavior, externalising, internalising, and syndrome scale scores. Moreover, a greater proportion of clinically referred Melbourne children scored below the CBCL clinical cutoff (T score 30) for the total social competence score, and activities and social subscales. Conversely, a greater proportion of the clinically referred American children scored above the cutoff for school problems. A comparison between a sub-sample of the Melbourne clinical (n = 1342) and Melbourne non-clinical (n = 1009) samples indicated a number of demographic risk factors among the referred sample, including lower maternal education, lower socio-economic status, and blended/split families. 4.2.2
A Sydney Clinical Sample
Rey, Grayson, Mojarrad and Walter (2002) retrospectively examined the rate of diagnosis of major depression in a sample of 1310 adolescents aged 12- to 17-years referred to a mental health service in Sydney between 1993 and 1997. Mean CBCL and YSR raw scores for the total problems scale, externalising scale, internalising scale and anxious/depressed scale and proportions of DSM diagnoses are reported in Table 6, Appendix 2. The study did not report correlations between the CBCL scores and DSM diagnoses. However, the CBCL and YSR total scores were seemingly non-specific to DSM diagnoses (Rey et al., 2002), as a wide variety of diagnoses were made. This is not surprising given that the CBCL total score provides an overall measure of behavioral and emotional problems. The study also indicated that the mean levels on the anxious/depressed subscale were consistent among children referred across the study time period (see Table 6, Appendix 2), suggesting that rates of anxious/depressed symptomatology did not change between 1993 and 1997. 4.2.3
Western Australian Clinic Samples
Paterson, Bauer, McDonald and McDermott (1997) compared data from a sample of 58 consecutive psychiatric inpatient children and adolescents (mean age 11.3 years, range 8- to 16-years) to the Western Australian Child Health Survey data on mean levels of total behavior and emotional problems according to the CBCL, YSR and TRF. Results are reported in Appendix 2, Table 7. The mean level of psychopathology was significantly higher and number of ‘cases’ identified significantly greater among the psychiatric inpatients according to all informants. Consistent with other studies examining cross 15
informant stability inpatient children reported significantly fewer problems than their parents, whilst the opposite is true for the normative sample. Paterson et al. also reported an approximately equal prevalence of internalising and externalising problems within the psychiatric sample. A study conducted by McDermott, McKelvey, Roberts and Davies (2002) compared levels of behavioral and emotional problems in children receiving treatment for behavioral and emotional problems in one of four treatment settings (inpatient care, day treatment, outpatient care and consultation only) in Western Australia. Both the CBCL and YSR were completed. There were significant differences across treatment settings in parent report of problems (see Appendix 2, Table 8), with inpatient and day treatment children rated as having significantly more total and externalising problems than children receiving treatment via an outpatient service or through consultation only. Inpatient children were rated as having significantly greater internalising problems than children receiving treatment via an outpatient service or through consultation only. The severity of problems reported in the inpatient and day treatment samples are comparable to the previously described inpatient sample (Paterson et al., 1997). Similar patterns emerged based on the YSR, which was completed by all children and adolescents aged 11- to 17 years, with the main difference being that young people in a day treatment program did not report more problems than children receiving outpatient care or consultation only. Competency levels were significantly lower in the inpatient and day treatment care than the outpatient care or consultation only, as indicated by both parent and self-report (see Appendix 2, Table 8).
4.3
Conclusions
The CBCL has been used to assess levels of problems among immigrant children living in Australia. Overall, immigrant children and adolescents are reported to have similar or fewer behavioral and emotional problems than Australian born non-referred children and adolescents and significantly lower levels of problems than referred Australian born children. The CBCL reports suggest that immigrant children may have poorer social competence than non-immigrant children. However, this may be due to cross-cultural differences in social behavior rather than poorer social competence, per se. Studies using clinical samples have reported mean total raw scores in excess of 60. Research has shown a greater proportion of Melbourne clinically referred children than the American clinical normative sample score within the clinical range and that parents of referred Australian children may report higher levels of problems than teachers. However, the mean level of both parent and teacher-reported problems are significantly greater among clinical samples compared to non-clinical samples. The difference between the level of problems of clinically referred children and adolescents and non-referred children and adolescents is much smaller when using the YSR. The mean level of parent- and child-reported behavioral and emotional problems and competencies has been shown to vary across treatment settings. Generally, greater problems were reported among inpatients compared to children receiving outpatient care or consultations only. While the studies reviewed provide some indication of morbidity rates and levels of problems among Australian samples, they are not conclusive. Samples are not necessarily representative of their respective populations (e.g. clinical, immigrant). Also, some of the studies were conducted quite some time ago and may not be indicative of current morbidity rates for their respective population. Further research regarding morbidity is required using normative samples and the most recent version of the CBCL.
16
5
Diagnostic Utility
5.1
Behavioral and Emotional Problems
5.1.1
A Western Australian Sample
5.1.1.1
WACHS Pilot Survey
The WACHS pilot survey conducted a clinical calibration study, which enabled evaluation of the CBCL as a screening diagnostic tool. Approximately 6-months after the initial pilot study, the Semi-Structured Clinical Interview for Children (SCIC), the Diagnostic Interview for Children and Adolescents – Revised (DICA-R), and clinical diagnosis following interviews were completed for the sample of 40 children (Garton et al., 1995). Using these assessments 20 cases and 20 non-cases were identified. Participants were also asked to complete the CBCL or YSR. Children who scored over the 98th percentile on at least one syndrome, irrespective of source (i.e. CBCL, YSR or TRF) were classified as a case. The ‘cases’ were randomly matched to ‘non-cases’ on age. There was a significant association between a high score on the CBCL (or alternate forms) and receiving a clinical diagnosis 6 months later. Receiver Operating Characteristics (ROC) Analysis was used to examine the sensitivity and specificity of the CBCL. Sensitivity is defined as the percentage of individuals correctly classified as a case. Specificity refers to the percentage of individuals correctly classified as a non-case. Both sensitivity (0.86) and specificity (0.72) were very good, suggesting that a large proportion of children were correctly classified as a case or non-case using the CBCL (or alternate form). The positive predictive value of the CBCL however was somewhat lower (0.65). There were no significant age or gender differences. 5.1.1.2
WACHS Main Survey
The WACHS main survey also conducted a clinical calibration study on a sub-sample of 166 ‘cases’ and a random sample of 80 ‘non-cases’ (Zubrick et al., 1997). Cases were defined as scoring at or above the 98th percentile on a CBCL syndrome score. The composition of cases was as follows: 33 attention problems, 34 delinquency or aggression, 64 depression/anxiety, 35 somatic. Overall, 139 (56.5%) were male and the average age at interview was 12.4 years (range 5-17 years) (Zubrick et al., 1997). Appropriate forms of the DICA were used with the parent and child/adolescent, the results of which were used to make clinical diagnoses. Sensitivity and specificity rates for CBCL and DICA classifications of certain disorders are reported in Appendix 3, Table 1. Classification rates of cases and non-cases were better than chance across all disorders (except classification of non-cases for somatisation). The best classification results were achieved for dysthymia based on the CBCL anxious/depressed subscale (0.88 sensitivity and 0.81 specificity). Unfortunately, the report does not specify the CBCL cut-off points used for classifications. 5.1.2 5.1.2.1
A Melbourne Sample Sensitivity and Specificity
The sensitivity and specificity of the CBCL was assessed using a Melbourne sample of 1342 children referred to a mental health outpatient service between July 1991 and October 1992 (Nolan et al., 1996). Relatively high sensitivity and specificity was reported, particularly for the total behavior score (0.77 17
sensitivity and 0.83 specificity), suggesting that the CBCL may be used as a tool to screen for children with clinically significant behavioral and emotional problems (see Appendix 3, Table 2) (Nolan et al., 1996). The sensitivity and specificity is similar to that for the American sample (Achenbach, 1991; Nolan et al., 1996). The authors suggest that “even if the community sample is less representative than desirable, the discriminability of the CBCL would remain at an acceptable level” (Nolan et al., 1996, p 410). 5.1.3
A Brisbane Sample
A random sample of 64 boys and 56 girls aged 12- to 14-years in Grade 8 at a Catholic school in Brisbane completed the YSR and participated in the Diagnostic Interview for Children, Adolescents and Parents (Johnson, Barrett, Dadds, Fox, & Shortt, 1999). Thirteen children were identified as meeting criteria for a DSM-IV disorder based on diagnostic interview. Though the number of children who met criteria for an internalising or externalising disorder was small, the respective mean YSR scales were significantly higher than a random selection of children who did not meet criteria for a diagnosis.
5.2
Anxiety Disorders
5.2.1
Identification of Anxiety Disorders
Johnson, Barrett, Dadds, et al. (1999) examined the utility of the CBCL to discriminate between a sample of 57 children and adolescents aged 6- to 16-years, recruited through the referral service at an anxiety disorders clinic in Brisbane. Using the Diagnostic Interview for Children, Adolescents and Parents, 40 children were found to have an anxiety disorder. Fifty-two mothers and 40 fathers completed the CBCL. Both parents reported higher levels of internalising problems than externalising problems; mother reported a mean level of 59.83 (SD = 12.73) for internalising problems and 49.50 (SD = 10.65) for externalising problems, whilst fathers reported a mean level of 56.35 (SD = 12.06) for internalising problems and 48.60 (SD = 10.07) for externalising problems. Discriminant function analyses revealed that internalising scores (as reported by mother and father) significantly discriminated children with an anxiety disorder from those without an anxiety disorder. In contrast, neither mother nor father reports of externalising problems discriminated between the groups. A greater proportion of children with an anxiety disorder (92% based on mother report and 96% based on father report) than without an anxiety disorder (71% based on mother report and 70% based on father report) were correctly classified. 5.2.2
Measure of Anxiety Severity
The CBCL has been utilised in studies examining anxiety disorders in children and adolescents (Barrett, Duffy, Dadds, & Rapee, 2001; Cobham, Dadds, & Spence, 1999; Dadds et al., 1999). A study conducted by Cobham, Dadds and Spence (1999) showed that the mean levels of maternal reported CBCL internalising problems was significantly higher amongst a sample of 33 children diagnosed with a DSM-IV anxiety disorder compared to a clinical control group of 20 children diagnosed with either Opposition Defiant Disorder, Attention-Hyperactivity Disorder or Conduct Disorder, who in turn scored significantly higher than a non-clinical sample of 20 children (see Appendix 3, Table 3). The CBCL internalising score was within the clinical range for children with anxiety whose parents also had anxiety. The CBCL internalising score was within the borderline range for the other two clinical groups. Self reported anxiety (using the RCMAS) was also significantly higher among the 20 children diagnosed with an anxiety disorder compared to the clinical and non-clinical control groups. However, the RCMAS 18
did not differentiate between the clinical control and non-clinical control groups. These results suggest that unlike the RCMAS, which is a specific anxiety measure, the CBCL may be useful in identifying internalising problems among children with primary externalising DSM diagnoses. An intervention study included 128 children aged between 7 and 14 years, recruited through schools in metropolitan Brisbane, who were identified as having anxiety problems (DSM-IV diagnosis of features) using the Anxiety Disorders Interview Schedule for Children - Parent Version (ADIS). Clinicians rated the severity and interference of the child’s problems on an 8-point scale (Dadds et al., 1999). Correlations of the clinician severity rating with the CBCL Internalising Scale at pre-treatment, posttreatment, and long-term follow-up (6- and 12-months) assessed the validity of the diagnostic interview. Dadds, Holland, Laurens, et al. (1999) concluded that the moderate level correlations (0.36 pre-treatment, 0.25 post-treatment, 0.51 6-month follow-up and 0.40 12-month follow-up) indicated acceptable validity of diagnostic ratings. Dadds et al. (1999) also examined the chronicity of anxiety problems by identifying predictors of anxiety diagnostic status at post-treatment and 24-month follow-up. A higher CBCL internalising score at pretreatment was predictive of having an anxiety disorder at post-treatment and 24-month follow-up. The CBCL externalising scale was not predictive of anxiety diagnostic status. Other significant predictors included being female and having a higher clinician severity rating at pre-treatment. Pre-treatment CBCL score was also predictive of clinician severity rating at post-treatment and 24-month follow-up. Thus, it appears that the CBCL internalising scale may be useful in identifying children at risk of ongoing anxiety problems, though the inclusion of other factors is likely to improve sensitivity. Barrett, Duffy, Dadds and Rapee (2001) used the CBCL to detect changes in levels of internalising problems amongst a group of 52 children and adolescent who participated in an intervention program for anxiety disorders. The Fear Survey Schedule for Children – Revised (FSSC-R), the Revised Children’s Manifest Anxiety Scale (RCMAS) and the Children’s Depression Inventory (CDI), self-report measures of fears, chronic anxiety and depression in children, respectively, were also employed to assess change from pre-treatment to 1-year and 6-year follow-up (age 14- to 21-years). Regardless of treatment condition (CBT only or combined CBT and family anxiety management), maternal and paternal reports of child internalising and externalising problems were significantly lower at 1-year and 6-year follow-ups compared to pre-treatment (see Appendix 3, Table 4). Though not significant, there was a slight increase in CBCL-I scores at 6-year follow-up compared to 1-year followup for the CBT+FAM treatment group. Similar results were reported for the FSSC-R and RCMAS, with reductions in self-reported fears and chronic anxiety at the 1-year follow-up. As with the CBCL, slight increases in self-reported fears, anxiety and depression were found for the CBT-FAM treatment group at the 6-year follow-up. Additionally, the CBT only treatment group also reported slight increases in fears, anxiety and depression at the 6-year follow-up. Use of the CBCL internalising clinical cutoff (T ≥ 65) also revealed that the majority of participants (83% based on mother report and 85.4% based on father report) fell within the non-clinical range. Overall, these results provide support for the use of the CBCL as an appropriate measure of change over a long period of time and as a potential method for identification of anxiety problems at a clinical level. It is important to note that non-inclusion of a control group limits the confidence in conclusions, as change in levels of internalising and anxiety problems may have partly been a function of age. A further 19
limitation of the study was the use of CBCL and self-report anxiety measures for individuals older than the measures’ normative samples.
5.3
Attention Deficit Hyperactivity Disorder
5.3.1
Diagnostic Utility
Rey, Morris-Yates and Stanislaw (1992) examined the accuracy of the CBCL hyperactivity factor as a method of identifying ADHD in adolescents. The sample comprised 385 boys aged 12- to 16-years attending an adolescent psychiatric unit in Sydney. Seventy-nine boys received a DSM-III diagnosis of ADHD and 306 boys were diagnosed with another DSM-III disorder. The mean CBCL hyperactivity scores of the ADHD sample was significantly higher than the non-ADHD group (14.81 compared to 9.45), lending some support for using the hyperactivity subscale as an indicator of ADHD. ROC analysis was used to assess the diagnostic utility of the hyperactivity subscale (Rey, Morris-Yates et al., 1992). ROC analysis calculates a statistic called ‘area under the curve’ (AUC). The AUC summarises the diagnostic utility of a scale as a diagnostic tool, in that an area greater than 0.50 indicates that the scale predicts diagnosis at a level better than chance. Rey et al. reported an AUC estimate of 0.83, thus supporting the validity of the CBCL hyperactivity scale and suggesting that it may be useful in diagnosing ADHD in adolescent boys aged 12- to 16-years. The ROC analysis also produces sensitivity and specificity statistics, based on selected cutoff points. In relation to the reported study, sensitivity refers to the proportion of adolescents with ADHD who were identified using the scale as having ADHD. Specificity refers to the proportion of adolescents without ADHD who were identified using the scale as not having ADHD. Sensitivities and specificities according to varying cutoff points along the CBCL hyperactivity subscale have been reproduced in Appendix 3, Table 5 (Rey, Morris-Yates et al., 1992). Clearly, there is a marked tradeoff between sensitivity and specificity. For example, a cutoff of 12 on the hyperactivity subscale will result in correct identification of 87% of adolescents with ADHD, whilst 13% of cases will be categorised as not having ADHD. However, a cutoff of 12 means that 65% of adolescents will be correctly categorised as not having ADHD, whilst 35% will be incorrectly categorised as having ADHD. 5.3.2
CBCL Scores Across DSM-IV ADHD Subtypes
The discriminant validity of the DSM-IV ADHD subtypes was assessed using a sample of 3,597 children and adolescents age 6- to 17-years who participated in the Child and Adolescent Component of the National Survey of Mental Health and Well-Being in Australia (Graetz, Sawyer, Hazell, Arney, & Baghurst, 2001). Parents participated in a diagnostic interview (parent version of the Diagnostic Interview Schedule for Children) and completed the CBCL as a measure of behavioral and emotional problems and the Child Health Questionnaire as a measure of quality of life. The overall prevalence of DSM-IV ADHD was 7.5%, with 133 children diagnosed with Inattentive type, 68 with Hyperactivity-Impulsive type and 67 with Combined type (Graetz et al., 2001). On all CBCL scale scores (excluding Somatic Complaints), children diagnosed with ADHD (any type) scored significantly higher than the control children (see Appendix 3, Table 6). On all CBCL scales, children with combined type scored significantly higher than children with inattentive or hyperactivity-impulsive types. Importantly, the inattentive group scored significantly higher than the hyperactivity-impulsive group on the CBCL scales measuring attention, anxiety/depression, somatic complaints and overall 20
internalising problems, whilst the hyperactivity-impulsive group scored significantly higher than the inattentive group on the externalising scales. Scores on the Child Health Questionnaire provided some validity for the finding that children with ADHD have significantly higher levels of behavioral and emotional problems. Furthermore, scores on the Child Health Questionnaire exhibited a similar discrimination pattern to the CBCL (on comparative scales) amongst the ADHD subtypes.
5.4
Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD)
5.4.1
Identification of an ODD and CD Factor
Exploratory factor analysis on 22 CBCL items (see Appendix 3, Table 7) corresponding to DSM-III ODD and CD criteria was conducted to examine the factor structure of conduct problems corresponding to symptoms of DSM-III-R ODD and CD (Rey & Morris-Yates, 1993). CBCL data for 528 adolescents (aged 12- to 16-years; 58% male) who had been referred to an adolescent psychiatric unit in Sydney was used for the analyses. One-hundred and eighty nine adolescents (126 boys) were diagnosed by a clinician as having CD, 75 (45 boys) with ODD, and 264 (138 boys) with another diagnosis, according to DSM-III. The factor analysis identified four factors (see Appendix 3, Table 7), labeled aggression, delinquency, oppositionality and escapism. One factor corresponded very closely to DSM-III-R ODD, with all CBCL items representing the factor related to DSM-III-R criteria. On the basis of the factor analysis and subsequent cluster analysis, Rey and Morris-Yates suggested the presence of a broad CD construct, with an underlying multidimensional structure, whereby some adolescents were characterised as ‘traditional’ CD (high scores on all four factors), and other adolescents were characterised by severe aggression and oppositional behavior and lower delinquency and escapism. The authors also argued for a phenomenological distinction between ODD and CD, based on a group of adolescents scoring high on the ODD factor only. 5.4.2
Symptom Level Among Children with ODD and CD
The CBCL has been utilised as a screening measure for the identification of children with conduct problems and as a measure of outcome following treatment for children with conduct problems (Luk, Staiger, Mathai, Field, & Adler, 1998). In a sample of 176 children referred to a regional child and adolescent mental health service in Victoria, 96 were identified as having at least three symptoms suggestive of oppositional defiant/conduct disorder according to the CBCL and/or TRF. Of these, 15 children had not exhibited conduct symptoms for more than six months and 34 children also met DSMIII-R criteria for ADHD (based on teacher telephone interview). A final sample of 32 children received a form of treatment for conduct problems. The mean level of CBCL externalising problems was within the clinical range (T score 71.2). Some validation for the CBCL externalising scale as a measure of oppositional and conduct problems was provided in this study, as the mean levels of the severity of oppositional defiant/conduct problems and irritability/aggressive behavior (using the Eyberg Child Behaviour Inventory and Rowe Behavioural Rating Inventories, respectively) were also above the clinical cutoff scores. In addition, following treatment each measure showed significant reductions with means falling below the clinical cutoffs. Rey, Bashir, Schwarz, et al. (1988) compared a group of 25 adolescents diagnosed with oppositional defiant disorder (ODD) to 43 adolescents diagnosed with conduct disorder (CD) who attended an adolescent unit in Sydney on the CBCL social competence, internalising, externalising and total problems scale. The groups were also compared on DSM Axis V rating, a measure of chronic adversity, and 21
demographic variables (age, gender, social class). Univariate analyses indicated that children with CD had significantly more externalising and total problems and poorer social competence than children with ODD. The mean levels of externalising and total problems within the CD group fell within the clinical range, while mean levels on the respective scales for the ODD group fell within the borderline range. The CD group was also rated by clinicians as having greater stressors within the past year according to DSM Axis V. There were no group differences on the CBCL internalising scale or demographic measures. Results are presented in Appendix 3, Table 8.
5.5
Depression
5.5.1
Development of a CBCL Depression Scale
The 1991 CBCL provides an anxious/depressed score, but not a validated depression subscale. However, Nurcombe, Seifer, Scioli, et al. (1989) conducted a principal components analysis and cluster analysis of the CBCL items using data gathered from 216 adolescent inpatients. Results from these analyses identified a depressive cluster of 22 CBCL items (see Appendix 3 Table 9). Nurcombe et al. demonstrated significant differences in scores on the Children’s Depression Inventory (in the expected direction) between 23 patients who scored high versus 23 patients (matched by age and gender) who scored low on the proposed CBCL depression scale, thus providing some support for the validity of the proposed scale. Importantly, the 21st Century CBCL scales include DSM-oriented Affective (depressive) Problems scales, which have been demonstrated to correlate with DSM diagnoses and with the Behavioural Assessment System (Reynolds & Kamphaus, 1992) for Children Depression scale. 5.5.2
Development of a YSR and CBCL Scale Equivalent to the CDI
Initial development of the YSR identified a 33-items depression subscale for females and a 20-item subscale for males, both of which were reported to correlate highly with the Children’s Depression Inventory (CDI) (Kovacs, 1981), which is a widely used self-report depression measure (Achenbach & Edelbrock, 1987). Hepperlin, Stewart and Rey (1990) examined the potential of using the CBCL and YSR to extracT scores obtained on the CDI. That is, they attempted to identify scales comprising CBCL or YSR items, which more closely corresponded to the CDI than the existing YSR depression subscale. The study utilised a clinical sample of 207 adolescents aged 11- to 18-years (126 boys) referred to a psychiatric unit in Sydney for assessment from February to December 1996. Items forming CBCL and YSR depression scales that were comparable to the CDI were selected on the basis of statistical analyses and face validity (refer to Hepperlin et al. (1990) for details). Fifteen YSR items (see Appendix 3 Table 10) were selected to comprise the ‘YSR-CDI scale’ (Hepperlin et al., 1990). The corresponding CBCL items were selected to comprise the ‘CBCL-CDI scale’. All of these 15 YSRCDI items were included in the original YSR depression subscale for females, whilst only 3 items also appear on other factors. For boys, 9 of the YSR-CDI items are included in the original YSR depression scale, while 6 items are included on the unpopular subscale and 5 items on the self-destructive/identity problems subscale. Internal consistency of both the YSR-CDI and CBCL-CDI scales was 0.81, whilst split half reliability was 0.78 and 0.79 respectively. There was a strong correlation (0.76) between the YSR-CDI and CDI. The CBCL-CDI and CDI were relatively poorly correlated (0.23). This may be due to different use of 22
informants across measures (as the CBCL-CDI was completed by the parent and CDI by the adolescent), or differences in the measures per se. Though the original YSR male and female subscales are somewhat longer than the 15-item scale identified by Hepperlin et al. (1990), they have the advantage of available normative data. Also, the correlations between the YSR depression subscales for females and males with the CDI are 0.75 and 0.65, respectively, which is comparable to the YSR-CDI and CDI correlation. Nevertheless, the study by Hepperlin et al. suggests that the use of the CDI may be redundant if assessment also incorporates the YSR. 5.5.3
Diagnostic Utility of Proposed Depression Scales
Rey and Morris-Yates (Rey & Morris-Yates, 1991, 1992) used ROC analysis to assess the accuracy of the depression scale proposed by Nurcombe et al. (1989) (discussed in Section 2), as well as five other CBCL and/or YSR subscales, in identifying adolescents with and without major depression. Data was obtained from a cohort of 667 adolescents (387 males) aged 12- to 16-years who had been referred to an adolescent unit in Sydney for psychiatric assessment between 1983 and 1986. Table 6 outlines the scales assessed, whilst items composing each scale are listed in Table 11, Appendix 3. Table 6. CBCL and YSR Measures of Depression (Taken from Rey and Morris-Yates (1991)) Scale name
Scale description
CBCL-NUR
CBCL 22-item scale identified by Nurcombe et al. (1989)
YSR-CDI
YSR 15-item scale identified by Hepperlin et al. (1990)
YSR-DEPB
YSR 20-item depression factor for boys extracted by Achenbach and Edelbrock (1987)
YSR-DEPG
YSR 32-item depression factor for girls extracted by Achenbach and Edelbrock (1987) Cross-informant anxious/depressed factor extracted by Achenbach, Connors and Quay et al. (1989) Addition of CBCL-NUR and YSR-CDI, divided by two
Anxious/depressed Composite
Extensive file reviews conducted by senior clinicians identified four diagnostic groups: 23 adolescents with major depression, 62 with dysthymia, 57 with separation anxiety, and 634 with ‘other’ diagnoses. The sample of adolescents with major depression scored significantly higher than the sample with dysthymia, separation anxiety, or ‘other’ diagnosis. Furthermore, adolescents with major depression scored higher than the group with dysthymia on the CBCL-NUR, YSR-DEPB and Composite scales. Mean score for each depression scale is reported in Appendix 3, Table 12. ROC analyses indicated that each depression scale discriminated between patients diagnosed with major depression and patients with ‘other diagnoses’, dysthymia and separation anxiety (Rey & Morris-Yates, 1991, 1992). However, the overlap of confidence intervals indicated no statistical difference in the accuracy of discrimination between each diagnostic group. Sensitivity and specificity estimates were not routinely reported for each scale. However, estimates that were reported indicated that the sensitivity (proportion of depressed patients identified by the scale as depressed) and specificity (proportion of non-depressed patients identified as not depressed) statistics for the CBCL-NUR scale were less impressive than overall accuracy. For example, Rey and Morris-Yates (1991) reported that a cutoff of 15 when differentiating between depressed patients with other diagnoses resulted in a sensitivity of 0.83 and a specificity of 0.55. Thus, whilst 83% of depressed patients were identified as such, 17% of depressed patients were incorrectly classified as not depressed. Furthermore, a 23
specificity of 0.55 means that 45% of non-depressed patients with ‘other’ diagnoses were actually identified as depressed. Rey and Morris-Yates (1991; 1992) concluded that the accuracy of the proposed depression scale to differentiate between patients with and without depression is comparable to other measures. However, given the moderate sensitivity and specificity statistics, it is probably safer to use the proposed depression scale as an indicator of possible depression rather than as a diagnostic tool.
5.6
Comorbidity
The CBCL has been used to examine the prevalence of comorbid disruptive disorders and depression. Rey (1994) used a sample of 840 adolescent girls and 1252 adolescent boys referred to a adolescent unit in Sydney for psychiatric assessment between 1983 and 1991. CBCL data was available for at least 90% of the cohort. Comparison data came from the American clinical cohort (adolescents aged 12- to 16years) used in the original CBCL factor analysis (Achenbach & Edelbrock, 1983). The CBCL was used as a diagnostic indicator of Depression, Hyperactivity (ADHD), Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). The CBCL Depression Scale (Nurcombe et al., 1989) and the original Hyperactivity Scale (Achenbach & Edelbrock, 1983) were used. The items listed in Table 45 were summed and a cutoff score equal to or greater than 22 for Depression and 14 for Hyperactivity were indicative of respective diagnoses. The CDD and OD scales were developed on the basis of discriminant function analysis, which identified CBCL items that demonstrated good discrimination between patients referred for ODD and CD. Items are listed in Table 7. It is noteworthy that not all items corresponded to DSM-III-R criteria. On the ODD scale, a cutoff of 15 indicated a diagnosis of ODD. On the CD scale, a cutoff of 7 indicated a diagnosis of CD.
24
Table 7. CBCL Items Making up the Different Scales (Taken from (Rey, 1994)) Oppositionality Item Item content 3. Argues 16. Cruelty 22. Disobedient, home 23. Disobedient, school 37. Fights 57. Attacks people 68. Screams 86. Stubborn 90. Swears 94. Teases 95 Tantrums 97. Threatens
Conduct Item Item content 15. Cruel to animals 21. Destroys property 43. Lying 72. Sets fires 81. Steals at home 82. Steals at school 67. Runs away 101. Truancy 105. Alcohol, drugs 106. Vandalism
Hyperactivity Item Item content 1. Acts too young 8. Can’t concentrate 10. Hyperactive 23. Disobedient, school 41. Impulsive 44. Bites fingernails 45. Nervous 61. Poor school work 62. Clumsy 74. Shows off
Depression Item Item content 13. Confused 14. Cries 18. Harms self 30. Fears school 31. Fears doing bad 32. Has to be perfect 35. Worthless 42. Alone 47. Nightmare 50. Fearful 52. Guilty 54. Overtired 56b.
Headaches
75. 77. 80. 91. 100. 102. 103. 111. 112.
Shy Sleeps more Stares blankly Suicidal Trouble sleeping Underactive Unhappy Withdrawn Worrying
Note: Item content is summarised
As with some other Australian prevalence studies, the mean levels of problems and prevalence of individual and comorbid disorders was substantially higher among the Australian population compared to the US normative sample (see Appendix 3, Table 13). However, the pattern of comorbidity across countries was similar. The odds of having comorbid Depression-ADHD or comorbid Depression-ODD were significantly greater than comorbid Depression-CD (see Appendix 3, Table 14). Analyses indicated that having a diagnosis of depression did not increase the risk of a diagnosis of CD, even in the presence of a diagnosis of ADHD or ODD. A clear limitation of this research is the lack of an external criterion and the fact that the CBCL scales used have not demonstrated 100% accuracy in classification of the disorders.
5.7
Conclusions
Sensitivity and specificity estimates are often used to assess the diagnostic utility of instruments. Sensitivity refers to the percentage of individuals correctly classified as a case. Specificity refers to the percentage of individuals correctly classified as a non-case. These statistics have been used in research to assess how well the CBCL can predict diagnosis in Australian samples. The WACHS demonstrated good sensitivity and specificity estimates for syndrome scales. All estimates indicated a better than random classification result (except specificity of somatisation). The best 25
classification results were achieved for a diagnosis of dysthymia based on the CBCL anxious/depressed subscale. Relatively good sensitivity and specificity estimates have been reported using the total behavior score with a Melbourne clinical sample. The hyperactivity subscale has been used to predict diagnosis of ADHD, with sensitivity and specificity estimates better than random. While best results were achieved with a cutoff of 12 or 14, a significant number of children were also misclassified. Combinations of various CBCL items have been shown to discriminate between adolescents with Major Depression and other mood and anxiety disorders. However, there seemed to be a large trade-off between sensitivity and specificity estimates and the overlap of confidence intervals indicated no statistical difference in the accuracy of discrimination between each diagnostic group. Another method of examining the diagnostic use of the CBCL has been to compare the mean levels of reported problems between samples of children and adolescents with and without specific disorders. Children with anxiety disorders have been reported to have significantly higher levels of CBCL internalising problems than children without an anxiety disorder. Research has shown the clinical utility of the CBCL internalising scale as a measure of change following treatment for anxiety disorders. However, anxiety specific measures are likely to provide a more sensitive measure of anxiety and change in levels of anxiety. It is also imperative to acknowledge that children with disorders aside from anxiety have also shown at least borderline levels of internalising problems on the CBCL (and related forms). Thus, the internalising scale may be limited as a diagnostic measure of anxiety. Children with ADHD have been reported to have significantly higher mean levels on the CBCL hyperactivity syndrome scale than children and adolescents with other disorders. Significant differences have been shown in levels of behavior problems between children with different subtypes of ADHD. In particular, compared to children with inattentive or hyperactive type, children with combined type have been shown to score significantly higher on the total problem scale, externalising scale, internalising scale and the majority of syndrome scales. Levels of externalising problems have been shown to be in the clinical and borderline ranges for children with CD and ODD, respectively. Children with CD have also been shown to have significantly poorer social competence according to the CBCL than children with ODD. The CBCL has also been used to examine the prevalence of comorbid disruptive disorders and depression. However, the lack of an external criterion limits the application of research findings. Similarly, mean levels of depression symptoms (using various combinations of CBCL items) have been shown to be significantly higher among adolescents diagnosed with Major Depression than for those diagnosed with Dysthymia, Separation Anxiety Disorder and ‘other’ disorders. Research has even suggested the use of YSR items, which correspond to the CDI (self-report depression scale), may replace the use of the CDI. However, use of the combination of YSR items corresponding to the CDI and the CDI are somewhat limited, as the scales do not have norms based on representative probability samples. In sum, despite the seemingly adequate sensitivity and specificity results, a number of children were also misclassified in the studies reviewed. In a clinical setting the rate of misdiagnosis is likely to be unacceptable. On the other hand, the CBCL may provide a useful indicator of the severity of several types of problems. It is therefore recommended that the CBCL total, broad-band and syndrome scales should not be used as a diagnostic tool, but rather as one of many tools in the assessment process. Hopefully, further research using Australian samples will be conducted to examine the diagnostic utility of the recent CBCL DSM derived scales (Achenbach, 2002). 26
6
Stability of Behavioral and Emotional Problems
The CBCL has been used to assess the stability of behavioral and emotional problems over varying lengths of time.
6.1
WACHS Pilot Study
As part of the WACHS pilot study, some participants completed the CBCL (n=37) or the YSR (n=18) on two occasions, yielding 8-week test-retest correlation coefficients of 0.87 and 0.76, respectively (Garton et al., 1995). For the main WACHS survey, the average 6-month test-retest reliability was 0.75 (Zubrick et al., 1997). These figures are comparable to reliability estimates reported by Achenbach (1991, cited in Zubrick, 1997 #80)
6.2
The Port Pirie Cohort Study
The Port Pirie Cohort Study commenced in 1979 with a sample of 723 infants (686 families) who lived in or around the non-metropolitan region of Port Pirie, South Australia (Sawyer, Mudge, & Carty, 1996). The main aim of the study was to investigate the impact of low-level lead exposure on child development. The CBCL was used to provide a measure of behavioral and emotional problems when the children were aged 5-years (n = 444 families). Cross-informant data (based on the CBCL, YSR and TRF) was obtained for 147 girls and 130 boys, aged 11- to 12-years. Analyses indicated no response bias with respect to the total number of behavioral and emotional problems, externalising problems, internalising problems, child sex, or paternal occupational class at age 5-years. The stability of behavioral and emotional problems over the 6-year period was assessed using Pearson r correlations between the CBCL at age 5-years and the CBCL, YSR and TRF at age 11- to 12-years. All correlations between maternal CBCL ratings across the time points were significant at p<0.01, with the majority having a medium to large effect (according to Cohen’s criteria) (see Appendix 4, Table 1). These 6-years stability correlations are similar to a 6-year stability estimate reported in a Dutch sample (Verhulst & van der Ende, 1992, cited in Sawyer, 1996 #63) and a 3-year stability estimate reported in a US sample (McConaughy, Stanger, & Achenbach, 1992, cited in Sawyer, 1996 #63). The correlations between mother report at age 5-years and self and teacher reports at age 11- to 12-years were consistently smaller (all had a less than medium effect with some close to zero). The low correlations between mother-teacher and mother-self are indicative of limited agreement between cross-informants. There were very few gender differences in regard to stability of problems. The prediction of the CBCL Withdrawn score at 11-12 years from CBCL Withdrawn at 5-years was stronger for girls than boys. The prediction of 11-12 YSR somatic complaints from CBCL somatic complaints at 5-years was stronger for girls, whilst the prediction of 11-12 YSR delinquent behavior from CBCL delinquent behavior at 5-years was stronger for boys. The number of ‘cases’ at age 5-years who remained as a ‘case’ at 11- 12-years assessed stability at an individual level. Children who scored above the 80th percentile on the total problem, internalising or externalising scales were classified as a ‘case’. A score below the 50th-percentile was defined as nonclinical, whilst a score at the 50th-to 80th-percentile was regarded as sub-threshold. Based on maternal report, approximately one-third of the 5-year-old children identified as cases were also rated as having clinically significant overall problems at age 11- to 12-years. An even greater proportion of children with clinically significant internalising or externalising problems at age 5-years continued to 27
have such problems at 11- to 12-years. However, approximately one quarter of children with internalising or externalising problems at age 5-years were no longer a ‘case’ at age 11-12 years. The stability of ‘caseness’ from maternal reports at age 5-years and self or teacher reports at 11- to 12-years was less apparent, which is not surprising given the relatively poor cross-informant correlations. Refer to Appendix 4, Table 2, for further details. The odds of having clinically significant levels of problems were also computed (see Appendix 5, Table 3). All were significant at p < .05. For an odds ratio to be significant, the lower level of the confidence interval must exceed 1.0. The odds rations indicated that child who had clinically significant levels of total problems at age 5-years were 2.6 times more likely to have clinically significant levels of problems according to the total score at age 11- to 12-years. The odds ratios for the internalising and externalising scales were 3.8 and 5.6, respectively. On the subscale scores, odds ratios ranged from 2.8 (thought problems) to 15.7 (social problems).
6.3
Conclusions
The short-term stability estimates reported in the WACHS indicates excellent reliability for the CBCL with an Australian population. The long-term correlations indicate relative stability in maternal ratings with lack of agreement between different informants (see Section 7 for a review of cross informant ratings). Research is required to examine potential factors associated with long-term stability of CBCL behavioral and emotional problems.
28
7
Cross Informant Stability
Assessment of behavioral and emotional problems in children and adolescents is complicated by the generally poor agreement between informants. A meta-analysis conducted by Achenbach, McConaughy and Howell (1987, cited in Rey, 1992 #24) indicated an average correlation of 0.25 between different informants (e.g. parent-child). Rates of agreement may be influenced by factors including item ambiguity, inference, threshold uncertainty, type of problems (e.g. internalising or externalising), age of child, and psychological state of informants (Rey, Schrader, & Morris-Yates, 1992). A few Australian studies have compared reports of behavioral and emotional problems in children and adolescents using the CBCL, YSR and TRF (Little, Hudson, & Wilks, 2000; Rey, Schrader et al., 1992; Sawyer, Baghurst, & Clark, 1992; Sawyer, Baghurst, & Mathias, 1992; Sawyer, Clark, & Baghurst, 1993). The CBCL, YSR and TRF have 89 cross-informant items, thus permitting comparisons of total behavior problem score, externalising and internalising scores, and some syndrome scores.
7.1
South Australian Community and Clinic Samples
Sawyer and colleagues (1993, 1992 #25, 1992 #26) compared the level of behavioral and emotional problems in a sample of 336 children aged 10- to 11-years and 14- to 15-years for whom appropriate questionnaires had been completed by two parents, the child and the teacher. The sample was selected from metropolitan schools in South Australia using a stratified sampling procedure. Response bias analysis suggests that the sample may be slightly under-representative of lower socio-economic class schools. 7.1.1
Mean Level of Problems in a Community Sample
The mean levels of total, internalising and externalising problems reported by different informants were compared across four gender-age groups (i.e. 86 males aged 10-11 years, 105 females aged 10-11 years, 71 males aged 14- 15 years, 74 females aged 14- 15 years) (Sawyer et al., 1993). Levels of total, externalising and internalising problems were calculated using only items present on all forms (CBCL, YSR and TRF). Across age groups and gender, youth mean scores for the total, internalising and externalising scales were significantly higher than mother, father and teacher reported mean scores (see Appendix 5, Table 1). Analyses also indicated that higher score reports by children was reflective of a greater number of problems endorsed, rather than greater severity of the same amount of problems. Mother and father were reports were most strongly correlated, whilst teacher and child reports had the lowest correlation (see Appendix 5, Table 2). 7.1.1.1
Parent and Child Comparisons
Children within all age by gender groups reported significantly more total, externalising and internalising problems than mothers and fathers (Sawyer et al., 1993). The size of the difference in level of problems reported was greatest between mothers and children aged 14-15 years. The difference between maternal and child reports varied according to gender. For older males the largest difference in number of problems reported was for internalising problems, whilst for females the largest difference was reported for externalising problems. The mean level of differences in total, externalising and internalising reports was greater between father and older females than father and younger females. However, the size of differences did not vary significantly between fathers and older males and fathers and younger males.
29
7.1.1.2
Teacher and Child Comparisons
Analyses indicated that teachers reported fewer problems than children within each age by gender group (Sawyer et al., 1993). The size of the difference between reports of total problems and internalising problems was not significantly greater between teacher and older male or female children compared to teacher and younger male or female children. 7.1.2
Clinical Caseness
The degree of overlap in mother, father, child and teacher reports of clinical levels of total behavior, internalising and externalising problems was not significant. The mean total, internalising and externalising problem scores were higher when based on child self-report than parent or teacher reports (Sawyer, Baghurst, & Clark, 1992; Sawyer et al., 1993). However, the prevalence estimate of ‘caseness’ was lowest when using child report and highest when using mother report, across all age by gender groups (Sawyer, Baghurst, & Clark, 1992) (see Appendix 5, Table 3). Twenty-four percent of males and 25% of females aged 10-11 years, 27% of males and 24% of females aged 14-15 years, were identified as ‘cases’ using the total behavior problem score from at least one informant. Child report produced the lowest number of ‘cases’ (22%), Mother reports identified the highest number of ‘cases’ (66%), followed by fathers (54%), then teachers (33%) (see Appendix 5, Table 4). Approximately 50% of ‘cases’ were identified as a case by only one informant. Thus, the moderate to high correlations between the total scores does not automatically mean that different informants agree with respect to the identification of children as clinical cases. 7.1.3
Mean Levels of Problems in Community and Clinic Samples
As previously reported, Sawyer and colleagues have shown in a South Australian community sample that children consistently report higher mean levels of behavioral and emotional problems (Sawyer, Baghurst, & Clark, 1992; Sawyer et al., 1993). A study was conducted to compare the levels of problems reported by different informants in a South Australian community sample of 83 children aged 10-11 years and 1415 years drawn from metropolitan schools and a clinic sample of 100 children aged 10-16 years (Sawyer, Baghurst, & Mathias, 1992). In contrast to the other reviewed studies by Sawyer and colleagues, children within the clinic group tended to report significantly lower levels of externalising problems than mothers, fathers and teachers (see Appendix 5, Table 5). The differences in child report compared to mother, father or teacher reports for externalising problems was significantly greater than the respective differences within the community group. That is, children within the clinic group were in less agreement with other informants with respect to externalising problems than were children within the community group. As with the community group, children within the clinic group reported more internalising problems than did their mothers, fathers or teachers (see Appendix 5, Table 6). Overall, there were minimal differences in the size of discrepancies between informants’ reports of internalising problems within the clinic group compared to the community group.
7.2
Victorian Clinical Sample
The level of conduct problems across home and school has been assessed using a sample of 124 children attending Victorian schools and 65 children (aged 5- to 14-years) referred to agencies for conduct problems (aged prep to Year 8) (Little et al., 2000). Using the externalising subscale of the CBCL there 30
was general consensus between teachers and parents in relation to the school children who did not have clinical levels of externalising problems (i.e. severe problems were not observed at school or home). Teachers and parents identified approximately 6% of children as having clinically significant externalising problems. However, 5% of children were reported to have problems at school but not at home, whilst 17% of children were reported to have problems at home but not at school. Within the clinical sample, 60% of children were reported to have clinically significant externalising behavior problems at both school and home. However, similar to the school sample, there was also some disagreement between parent and teacher reports, with 8% of children reported to have clinically significant problems at school only and 25% to have clinically significant problems at home only. Taken together, these findings may be interpreted in a couple of ways. As suggested by the authors (Little et al., 2000), it is possible that some children do behave differently across contexts, and exhibit significant levels of externalising behavior problems at either school or home, but not both. However, it is also possible that parent and/or teacher reports of the levels of externalising problems are biased. Unfortunately, this study did not incorporate other measures such as parental adjustment to assess potential biases,.
7.3
A Sydney Clinical Sample
Rey, Schrader and Morris-Yates (1992) examined levels of agreement between parent and child responses on the 102 items shared by the CBCL and YSR. The sample comprised 1299 children (and parent) aged 12- to 16-years who had been referred to an adolescent psychiatric unit in Sydney during 1983 and 1986. Overall, results were similar to that reported by the Achenbach meta-analysis (Achenbach et al., 1987, cited in Rey, 1992 #24), with an average Pearson-r correlation of 0.28 (range: 0.08-0.72) and kappa agreement of 0.24 (range: 0.07-0.71). Agreement was higher for externalising items than internalising items. Strongest correlations were found for factual items specific to neither externalising nor internalising problems (e.g. asthma 0.72). Of the externalising items, strongest correlations were found between more observable behaviors (e.g. running away from home 0.63, truancy 0.54, stealing 0.50), whilst close to zero correlations were found for more subjective items (e.g. stubborn, doesn’t feel guilty). Only one internalising item showed parent-child agreement above 0.40 (teased 0.41). Moderate agreement was shown for suicidal ideation (0.40) and suicide attempts (0.38). Of the internalising items, lowest agreement was shown for the item assessing jealousy (0.09). Rey et al. (1992) reported no direct impact of child gender or age on parent-child agreement. Only one age-gender interaction emerged, whereby parent-child agreement was stronger for older boys than younger boys.
7.4
Conclusions
Important findings, which emulate results from international research, have emerged in Australian studies examining cross informant stability. Most importantly are the differences between parent and child reports. In both community and clinical populations, children and adolescents (irrespective of gender) report significantly higher levels of internalising problems than mothers, fathers and teachers. This finding highlights the subjective nature of internalising problems and difficulties and limitations imposed on assessment. It is therefore vital to obtain self-reports of internalising problems, even from very young children. 31
Children in community samples also report significantly higher levels of externalising problems than do parents and teacher, again stressing the importance of obtaining self-reports. Children may report higher levels of problems because they are able to review their behaviors across all contexts. In contrast, children in clinical samples report fewer externalising problems than parents and teachers, while parents and teachers show moderate agreement for mean levels of problems. In relation to clinic samples, these findings seem to indicate a possible denial or even lack of insight on behalf of the young person regarding the severity of externalising problems. Within clinical samples mothers and fathers generally show high agreement, and mother/fathers and teachers show moderate agreement regarding mean levels of problems and clinical caseness. However, research also indicates a substantial disagreement between informants. Indeed, within community samples, parent-teacher agreement has been reported to be very low. Reasons for disagreement between reports may be multi-faceted. Factors such as parental mental health, informant opinions regarding what is a problem (e.g. teachers may place more emphasis on externalising problems), and contextual factors need to be considered. In sum, in a clinical setting best practice will incorporate parent, teacher and self-reports of the child functioning, as well as an assessment of all potentially confounding factors.
32
8
Biopsychosocial Factors and CBCL Reports
Studies have indicated a range of psychosocial factors associated with CBCL scores. For example, the WACHS survey reported significant associations between child mental health morbidity and family discord, family unemployment and poor parental mental health (Zubrick et al., 1996). This section reports Australian research findings regarding factors that are potentially associated with assessment of child and adolescent behavioral and emotional problems.
8.1
School related problems
8.1.1 Academic problems The WACHS survey report indicated that mental health problems, particularly attention problems and social problems, as assessed by the CBCL/TRF syndrome scales were predictive of low academic performance (see Table 8) (Zubrick et al., 1997). For example, the odds of having academic problems were increased by 4.0 times if the young person had clinically significant attention problems. Table 8. Predicted Risk for Low Academic Competence Associated with Mental Health Problems (Taken from Zubrick (1997)) Syndrome
Odds ratio
95% confidence interval
Delinquent problems
1.4
0.8-2.4
Thought problems
1.2
0.7-2.0
Attention problems
4.0
2.4-6.8
Social problems
2.7
1.6-4.8
Somatic complaints
1.1
0.6-2.0
Aggressive behavior
1.6
0.9-2.8
Anxiety/depression
0.5
0.2-0.9
Withdrawn
0.9
0.4-2.0
8.1.2
Bullying
According to the WACHS survey, an estimated 5% of students (8% boys and 3% girls) engage in some type of bullying behavior (Zubrick et al., 1997). Morbidity rates for syndromes and overall behavioral and emotional problems were significantly higher for children identified as bullies (83%) compared to non-bullying children (18%),
8.2
Parental Mental Health
Najman, Williams, Nikles et al. (2001) attempted to examine potential biases in maternal reports of child behavioral and emotional problems. Prior research has suggested that maternal reports of child behavioral problems are influenced by the mothers’ mental state. For example, parents with poorer psychological adjustment may focus more heavily on and report more problematic child behaviors and emotions. In contrast, parents with very good psychological adjustment may view their child in a particularly positive manner and minimise problems.
33
In 1981-1984, Najman et al. (2001) approached 8556 pregnant women presenting at major public hospitals in Queensland to participate in a longitudinal study of pregnancy and outcomes. When the children were aged 14-years, 5277 mother and children completed the CBCL and YSR, respectively. Mothers also completed a self-report measure of anxiety and depression. Analyses indicated a trend for a stronger association between maternal reports, as opposed to child reports, of child internalising and externalising problems, to be associated with maternal depression/anxiety. Overall, 43-46% of mothers agree with their children in relation to the levels of internalising problems, whilst there was an agreement rate of 46-47% for externalising problems. Mothers with ‘normal’ levels of anxiety/depression reported fewer internalising and externalising problems of their child, than did the children themselves. In contrast, mothers with clinically significant levels of anxiety/depression reported more internalising and externalising problems of their child, than did the children themselves. Najman et al. (2001) also conducted a sensitivity/specificity analysis in regard to child ‘case’ identification using the YSR as the ‘gold standard’ and the CBCL. Overall, mothers and children demonstrated poor agreement with regard to clinically significant levels of child internalising, externalising and total problems. For mothers who were not emotionally impaired (n=4108), agreement with YSR for child case identification was 20-25%. Mothers with ‘borderline’ (n=654) levels of anxiety/depression agreed more with their children in regard to child case identification. However, more mothers with ‘borderline’ anxiety/depression also identified their child as a case when the child did not identify him/herself as a case. A similar pattern emerged when the mothers had clinically significant levels of anxiety/depression (n=515). Thus, increasing sensitivity (agreement between mother-child reports of child case) was associated with a reduction in specificity (agreement in mother-child reports of child non-case). The previously discussed study by Cobham, Dadds and Spence (1999) provided some evidence to suggest that maternal reports of CBCL internalising problems may be influenced by levels of maternal anxiety. Within this study, there was a group of 33 children aged 7- to 14-years diagnosed with an anxiety disorder; of these children, 16 had mothers who also scored within the clinical range of self-reported anxiety. Despite no difference in the children’s clinician severity ratings of anxiety, mothers with higher levels of anxiety (rated using the State-Trait Anxiety Inventory) perceived their child to have higher levels of internalising problems (Mean 72.9) than mothers with lower levels of anxiety (Mean 65.5).
8.3
Child Gender
Najman et al. (2001) also conducted a sensitivity and specificity analysis of CBCL caseness by maternal mental health and child gender. Analyses indicated that mothers agreed more with their sons than daughters in relation to clinical levels of externalising problems, but this difference did not occur at nonclinical levels. In contrast, mothers agreed more with their daughters than sons for clinical levels of internalising problems, but not for non-clinical levels. Analyses indicated that a greater proportion of mothers and sons than mothers and daughters agreed in regard to clinically significant levels of externalising problems (sensitivity). However, mothers were also more likely to attribute clinically significant levels of externalising problems to sons than daughters when the child did not identify him or herself as a case (specificity). In relation to internalising problems, a greater proportion of mothers and daughters than mothers and sons agreed in regard to clinically significant levels of internalising problems (sensitivity). However, mothers were also more likely to attribute clinically significant levels of internalising problems to daughters than sons when the child did 34
not identify herself/ himself as a case (specificity). These gender differences in maternal attribution of externalising problems to boys and internalising problems to girls were irrespective of the level of maternal anxiety/depression.
8.4
Demographic factors
The National Survey of Mental Health and Wellbeing (Sawyer et al., 2000) indicated the following demographic risk factors for clinically significant or sub-threshold problems: step/blended or sole parent family composition, household income <$500/week, having a parent who left school < 17-years and parental unemployment. Sawyer, Sarris, Baghurst, Cornish and Kalucy (1990) examined the prevalence of clinically significant levels of emotional and behavioral problems in children attending schools of varying socio-economic status in metropolitan Adelaide. The final sample consisted of 358 children aged 10- to 11-years and 338 children aged 14- to 15-years. School socioeconomic status was rated according to the number of children in the school receiving benefits from the Government Assistance Scheme. School Group1 was ranked as having higher SES than School Group 2, which in turn had higher SES ranking than School Group 3. Sawyer et al. utilised the cut off scores recommended by Achenbach (1983) based on the US normative sample and the higher cut off scores recommended by Hensley (1988) based on an Australian normative sample. The number of ‘cases’ identified varied according to whether the US or Australian cutoff scores were used. However, parent report identified a significantly greater number of children within the lowest socioeconomic group (school group 3) as a ‘case’, regardless of whether the US or Australian cutoff scores were employed. Prevalence reports are shown in Appendix 6, Table 1. Bor, Najman, Anderson et al. (1997) conducted a longitudinal study of 8556 women recruited through two major obstetric hospitals in Brisbane during their pregnancy. The women were followed up over a 5year period. At 5-years data regarding family income, maternal dyadic and psychosocial adjustment, parenting, and child behavior and emotional problems was available for 5296 subjects. Low-income subjects were defined as living near or below the poverty line in Australia (pre-natal and 6-month followup: < $10,400/year; 5-year follow-up: < $15,600/year). The measure of child behavior and emotional problems was obtained using a shortened version of the CBCL, which contained 33 items of “the more commonly occurring behavior problems” (Bor et al., 1997, p. 667). A scale of externalising problems contained 11 items, whilst the scale of internalising problems contained 10 items. Bor et al. (1997) also created a social/attentional/thought problems (SAT) scale using CBCL items. Unfortunately items included in each scale were not reported. Some validation of the shortened scales was provided using a sub-sample of 76 participants who completed the entire CBCL when their child was 5-years-old. Consistent with Achenbach’s clinical cut-offs, the 90th percentiles were used for clinical cut-off scores. Analyses indicated a direct linear association between family income and child behavior and emotional problems, whereby the association between low income and child problems strengthened according to the chronicity of economic disadvantage (see Appendix 5, Table 2) (Bor et al., 1997). Similarly, analyses revealed significant linear and direct associations between family income and parenting, maternal dyadic and psychosocial adjustment factors. Univariate analyses also revealed that child externalising, internalising and SAT problems at 5-years were associated with some parenting behaviors (punishment by smacking or taking object from child), and maternal smoking, dyadic adjustment and depression. Multivariate analyses indicated that the relationship between family income and child problems is largely 35
mediated by maternal psychological adjustment, whereby mothers with a low family income are more likely to experience higher levels of depression and higher levels of maternal depression were related to greater child problems. The direct links between family income and child externalising and internalising problems largely disappeared after inclusion of maternal depression. However, a direct link between family income and child SAT remained even after inclusion of maternal adjustment. Measures of child behavior were based on maternal report only. Thus, it is possible that depressed mothers had distorted perceptions of their children, thus inflating the association between maternal psychological adjustment and child behavioral problems.
8.5
Conclusions
Potentially, there are many reasons why informants report discrepant levels of behavioral and emotional problems in children. The differences reported may reflect real differences in the child’s behavior across different contexts. Differences in reports may also be reflective of certain informant biases. Research using the CBCL (and related forms) with Australian samples regarding factors associated with reports has produced findings comparable to a large body of international research. Reports of child behavioral and emotional problems may be influenced by many ecological factors, including parental mental state, child gender, and socio-economic status. As the preceding section highlighted, a thorough assessment of child behavioral and emotional problems will incorporate measures of many biopsychosocial factors.
36
9
Final Remarks
This report has provided an overview of selected Australian research using the CBCL and related forms. Appendix 2 (Section 11.3) provides an extensive list of published research which has used the CBCL and related forms with a variety of Australian populations. Research reviewed indicates that the factor structure of the CBCL has predominantly been replicated among a large New South Wales clinical sample. In particular, there is evidence to support use of the following factors and syndromes, at least within clinical settings: Total behavior score, withdrawn, somatic complaints, anxious/depressed, thought problems, delinquent, and aggressive behavior. Conversely, less confidence may be placed in use of the attention and social problems syndrome scales. There is some empirical evidence that non-referred children in New South Wales have greater levels of behavior and emotional disturbance than the American normative sample. However, Melbourne children have been shown to have relatively similar levels of disturbance compared to the American normative sample. The American clinical cut-offs may therefore not be appropriate for all Australian children and adolescents. Use of the American cut-offs may inflate the degree of morbidity among Australian children and adolescents. Further normative research using Australian samples is required. The CBCL scales may provide insight into the specific types and severity of behavioral and/or emotional problems experienced by Australian children and adolescents. Research using Australian samples has identified potential scales for the assessment of disorders such as Major Depression, ODD and CD. However, the CBCL (and related forms) should not be used as a diagnostic tool. Research examining the recently devised CBCL DSM subscales using Australian populations is required. In line with international research findings, cross-informant reports (using the CBCL, TRF and YSR) using Australian samples indicate poor to moderate agreement regarding levels of behavioral and emotional problems. It seems imperative to obtain self-reports, particularly of internalising problems. Ideally, reports from all informants should be obtained. Contextual factors and potential biases, including parental mental health, socio-demographic characteristics, and other child characteristics need to be considered when interpreting results obtained on the CBCL (and related forms). Overall, empirical research provides support for use of the CBCL (and related forms) as a measure of behavioral and emotional problems among Australian children and adolescents. However, users of the CBCL need to be mindful of limitations associated with the application of American normative data and factor structure to Australian populations. Users must also make concerted efforts to remain well informed of emerging research, which will hopefully provide further insight regarding the use of the CBCL within Australia.
37
10
References
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Najman, J. M., Williams, G. M., Nikles, J., Spence, S., Bor, W., O'Callaghan, M., LeBrocque, R., Andersen, M. J., & Shuttlewood, G. J. (2001). Bias influencing maternal reports of child behaviour and emotional state. Social Psychiatry and Psychiatric Epidemiology, 36, 186-194. Nolan, T. M., Bond, L., Adler, R., Littlefield, L., Birleson, P., Marriage, K., Mawdsley, A., Salo, R., & Tonge, B. J. (1996). Child Behaviour Checklist classification of behaviour disorder. Journal of Paediatrics and Child Health, 32. Nurcombe, B., Seifer, R., Scioli, A., Tramonyana, M. G., Grapentine, W. G., & Beauchesne, H. C. (1989). Is major depressive disorder in adolescence a distinct diagnostic entity? Journal of the American Academy of Child and Adolescent Psychiatry, 28, 333-342. Paterson, R., Bauer, P., McDonald, C. A., & McDermott, B. (1997). A profile of children and adolescents in a psychiatric unit: Multidomain impairment and research implications. Australia New Zealand Journal of Psychiatry, 31, 682-690. Rey, J. M. (1994). Comorbidity among disruptive disorders and depression in referred adolescents. Australia New Zealand Journal of Psychiatry, 28, 106-113. Rey, J. M., Bashir, M. R., Schwarz, M., Richards, I. N., Plapp, J. M., & Stewart, G. W. (1988). Oppositional disorder: Fact or fiction? Journal of the American Academy of Child and Adolescent Psychiatry, 27, 157-162. Rey, J. M., Grayson, D., Mojarrad, T., & Walter, G. (2002). Changes in the rate of diagnosis of major depression in adolescents following routine use of a depression rating scale. Australia New Zealand Journal of Psychiatry, 36, 229-233. Rey, J. M., & Morris-Yates, A. (1991). Adolescent depression and the Child Behavior Checklist. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 423-427. Rey, J. M., & Morris-Yates, A. (1992). Diagnostic accuracy in adolescents of several depression rating scales extracted from a general purpose behavior checklist. Journal of Affective Disorders, 26, 7-16. Rey, J. M., & Morris-Yates, A. (1993). Are oppositional and conduct disorders of adolescents separate conditions? Australia New Zealand Journal of Psychiatry, 27, 281-287. Rey, J. M., Morris-Yates, A., & Stanislaw, H. (1992). Measuring the accuracy of diagnostic tests using receiver operating characteristics (ROC) analysis. International Journal of Methods in Psychiatric Research, 2, 39-50. Rey, J. M., Schrader, E., & Morris-Yates, A. (1992). Parent-child agreement on children's behaviours reported by the Child Behavior Checklist (CBCL). Journal of Adolescence, 15, 219-230. Sawyer, M. G., Arney, F. M., Baghurst, P. A., Clark, J. J., Braetz, B. W., Kosky, R. J., Nurcombe, B., Patton, G. C., Prior, M. R., Raphael, B., Rey, J. M., Whaites, L. C., & Zubrick, S. R. (2001). The mental health of young people in Australia: Key findings from the child and adolescent component of the national survey of mental health and well-being. Australia New Zealand Journal of Psychiatry, 35, 806814.
40
Sawyer, M. G., Baghurst, P., & Clark, J. (1992). Differences between reports from children, parents, and teachers: Implications for epidemiological studies. Australia New Zealand Journal of Psychiatry, 26, 652660. Sawyer, M. G., Baghurst, P., & Mathias, J. (1992). Differences between informants' reports describing emotional and behavioral problems in community and clinic-referred children: A research note. Journal of Child Psychology & Psychiatry, 33, 441-449. Sawyer, M. G., Clark, J. J., & Baghurst, P. (1993). Childhood emotional and behavioural problems: A comparison of children's reports with reports from parents and teachers. Journal of Paediatrics and Child Health, 29, 119-125. Sawyer, M. G., Kosky, R. J., Graetz, B. W., Arney, F., Zubrick, S. R., & Baghurst, P. (2000). The National Survey of Mental Health and Wellbeing: the child and adolescent component. Australia New Zealand Journal of Psychiatry, 34, 214-220. Sawyer, M. G., Mudge, J., & Carty, V. B., McMichael, A. (1996). A prospective study of childhood emotional and behavioural problems in Port Pirie, South Australia. Australia New Zealand Journal of Psychiatry, 30, 781-787. Sawyer, M. G., Sarris, A., Baghurst, P., Cornish, C. A., & Kalucy, R. S. (1990). The prevalence of emotional and behavior disorders and patterns of service utilisation in children and adolescents. Australia New Zealand Journal of Psychiatry, 24, 323-330. Verhulst, F. C., & van der Ende, J. (1992). Six-year stability of parent-reported problem behaviour in an epidemiological sample. Journal of Abnormal Child Psychology, 20, 595-610. Zubrick, S. R., Silburn, S. R., Garton, A., Burton, P., Dalby, R., Carlton, J., Shepherd, C., & Lawrence, D. (1995). Western Australian Child Health Survey: Developing health and well-being in the Nineties. Perth, Western Australia: Australian Bureau of Statistics and the Institute for Child Health Research. Zubrick, S. R., Silburn, S. R., Garton, A., Burton, P., Dalby, R., Carlton, J., Shepherd, C., & Lawrence, D. (1996). Western Australian Child Health Survey: Family and community health. Perth, Western Australia: Australian Bureau of Statistics and the TVW Telethon Institute for Child Health Research. Zubrick, S. R., Silburn, S. R., Gurrin, L., Teoh, H., Shepherd, C., Carlton, J., & Lawrence, D. (1997). Western Australian Child Health Survey: Education, health and competence. Perth, Western Australia: Australian Bureau of Statistics and the TVW Telethon Institute for Child Health Research.
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11
Appendices
11.1
Appendix 1: Use of CBCL Across Australia - Associated Tables
Table 1. CBCL Mean Raw Scores and T-Values for Boys Aged 4- to 5-Years (Taken from Hensley (1988)(1988)) Australian American t-value (n = 100) (n = 100) Activities 7.4 6.6 2.75 Social
5.3
6.3
-4.67
Total Social Competence
12.6
12.9
-0.75
Internalising
16.8
9.7
6.44
Externalising
19.2
11.3
6.27
Total Behavior Problems
39.9
24.1
7.13
Table 2. CBCL Mean Raw Scores and T-Values for Boys Aged 6- to 11-Years (Taken from Hensley (1988)(1988)) Australian American t-value (n = 300) (n = 300) Activities 7.6 7.9 -1.88 Social
6.5
7.2
-4.70
School
4.9
4.9
0.00
Total Social Competence
19.2
20.1
-3.39
Internalising
13.5
8.4
8.04
Externalising
15.2
10.8
6.18
Total Behavior Problems
32.8
21.7
8.23
Table 3. CBCL Mean Raw Scores and T-Values for Boys Aged 12- to 16-Years (Taken from Hensley (1988)(1988)) Australian American t-value (n = 250) (n = 250) Activities 7.4 8.0 -3.35 Social
6.7
7.8
-6.64
School
4.7
4.9
-2.35
Total Social Competence
19.0
20.7
-5.67
Internalising
12.3
7.4
7.20
Externalising
12.7
8.4
5.72
Total Behavior Problems
28.3
17.5
7.66
42
Table 4. CBCL Mean Raw Scores and T-Values for Girls Aged 4- to 5-Years (Taken from Hensley (1988)(1988)) Australian American t-value (n = 100) (n = 100) Activities 7.2 7.2 0.00 Social
5.7
6.3
-2.57
Total Social Competence
12.9
13.6
-1.73
Internalising
15.8
10.8
4.03
Externalising
12.0
8.4
3.82
Total Behavior Problems
33.9
25.2
3.76
Table 5. CBCL Mean Raw Scores and T-Values for Girls Aged 6- to 11-Years (Taken from Hensley (1988)(1988)) Australian American t-value (n = 300) (n = 300) Activities 8.3 7.9 2.64 Social
6.3
7.2
-5.95
School
5.3
5.3
0.00
Total Social Competence
20.0
20.4
-1.55
Internalising
11.7
7.7
7.35
Externalising
16.4
10.7
7.48
Total Behavior Problems
31.0
19.9
9.27
Table 6. CBCL Mean Raw Scores and T-Values for Girls Aged 12- to 16-Years (Taken from Hensley (1988)(1988)) Australian American t-value (n = 250) (n = 250) Activities 7.9 7.9 0.00 Social
6.5
7.5
-5.87
School
5.0
5.3
-4.19
Total Social Competence
19.4
20.8
-4.74
Internalising
13.5
7.0
9.97
Externalising
12.4
7.3
6.80
Total Behavior Problems
30.4
16.6
9.98
43
Table 7. Clinical Cutoffs (90th Percentile) for the Total Behavior Problem Score (Taken from Hensley (1988)) Girls
Boys
Age (years)
Australian
American
Australian
American
4-5
53
42
56
42
6-11
49
37
55
40
12-16
49
37
45
38
Note. For Tables 8 to 13: SW = Social Withdrawal D = Depressed I = Immature S = Somatic SP = Sex problems SZ = Schizoid A = Aggressive DQ = Delinquent O = Obese
H = Hyperactive OC = Obsessive Compulsive U = Uncommon SC-O = Schizoid Obsessive C = Cruel H-WD = Hostile Withdrawal A-O = Anxious Obsessive D-W = Depressed Withdrawal I-H = Immature Hyperactive
Table 8. 98th Percentiles for the Behavior Problem Scales for Boys Aged 4- to 5-years SW
D
I
S
SP
SZ
A
DQ
Australian
12
22
10
3
3
6
34
10
American
6
13
8
2
2
5
20
5
Table 9. 98th Percentiles for the Behavior Problem Scales for Girls Aged 4- to 5-years SW
D
O
S
SP
SZ
A
H
Australian
11
12
6
11
5
11
19
11
American
8
13
5
10
3
12
18
8
44
Table 10. 98th Percentiles for the Behavior Problem Scales for Boys Aged 6- to 11-years SW
D
OC
S
DQ
SZ
A
H
U
Australian
6
15
13
5
9
7
26
11
9
American
6
12
9
4
5
4
20
10
6
Table 11. 98th Percentiles for the Behavior Problem Scales for Girls Aged 6- to 11-years SW
D
SZ-O
S
DQ
C
A
H
SP
Australian
10
17
5
8
4
4
26
12
4
American
6
13
4
7
3
4
21
10
3
Table 12. 98th Percentiles for the Behavior Problem Scales for Boys Aged 12- to 16-years S
SZ
OC
I
DQ
H-WD
A
H
U
Australian
9
7
7
7
8
10
23
12
14
American
7
5
6
4
7
9
21
9
13
Table 13. 98th Percentiles for the Behavior Problem Scales for Boys Girls 12- to 16-years A-O
S
SZ
D-W
I-H
DQ
A
C
Australian
17
5
6
14
13
15
25
7
American
14
3
4
10
8
12
22
4
Table 14. Clinical Cutoffs (10th Percentile) for the Total Social Competence Score Girls
Boys
Age (years)
Australian
American
Australian
American
4-5
9.0
10.0
8.0
9.5
6-11
15.5
16.5
15.0
16.0
12-16
15.0
16.5
14.0
16.0
45
Table 15. Clinical Cutoffs (10th Percentile) for the Activities Score Girls
Boys
Age (years)
Australian
American
Australian
American
4-5
2.0
3.4
1.5
2.5
6-11
3.5
2.9
2.5
3.5
12-16
3.9
3.0
2.0
3.5
Table 16. Clinical Cutoffs (10th Percentile) for the Social Score Girls
Boys
Age (years)
Australian
American
Australian
American
4-5
2.0
2.5
2.0
3.7
6-11
2.5
3.5
2.0
3.3
12-16
3.0
3.0
3.0
3.8
Table 17. Clinical Cutoffs (10th Percentile) for the School Score Girls
Boys
Age (years)
Australian
American
Australian
American
4-5
-
-
-
-
6-11
3.0
3.3
2.7
2.3
12-16
2.7
3.0
2.3
2.3
46
Table 18. Nationality Differences on Problem Behavior Items and Total Score (Taken from Achenbach et al. (1990)) < 1% variance 1. Acts too young 4. Asthma 10. Can’t sit still, restless, hyperactive 12. Lonely 15. Cruel to animals 38. Is teased 42. Likes to be alone 44. Bites fingernails 48. Not liked 51. Dizzy 53. Overeating 56b. Headaches 56c. Nausea, feels sick 59. Plays with sex parts in public 63. Prefers older children 76. Sleeps little 84. Strange behavior 91. Suicidal talk 100. Trouble sleeping 101. Truancy 104. Unusually loud 105. Alcohol or drugs
Small effect size 3. Argues a lot 5. Behaves like opposite sex 8. Can’t concentrate 11. Too dependent 13. Confused 14. Cries a lot 17. Daydreams 19. Demands attention 22. Disobedient at home 26. Lacks guilt 29. Fears 32. Needs to be perfect 33. Feels unloved 34. Feels persecuted 35. Feels worthless 36. Accident prone 37. Fighting 39. Hangs around children who get into trouble 40. Hears things that aren’t there 41. Impulsive 43. Lying or cheating 45. Nervous 46. Nervous movements 50. Too fearful or anxious 54. Overtired 56a. Aches or pains 56f. Stomach aches, cramps 56h. Other physical problems 57. Attacks people 58. Picking 62. Clumsy 65. Refuses to talk 68. Screams a lot 69. Secretive 71. Self conscious 74. Showing off
Medium effect size 83. Stores up unneeded things 112. Worrying 60. Plays with sex parts too much 90. Swearing or obscene language Total Problem Score
47
Large effect size 96. Thinks about sex too much
75. Shy or timid 77. Sleeps much 80. Stares blankly 86.Stubborn, sullen, or irritable 87. Moody 88. Sulks a lot 89. Suspicious 92. Talks or walks in sleep 93. Talks too much 94. Teases a lot 95. Temper tantrums 97. Threatens people 99. Too concerned with neatness 102. Underactive 103. Unhappy, sad or depressed 109. Whining 111. Withdrawn 113. Other problems Table 19. Nationality Differences on Competence Items and Scores (Taken from Achenbach, et al. (1990)) < 1% variance Small effect size Medium effect size IIc. Skill in activities IVa. Number of jobs Ia. Number of sports IIIa. Number of organisations Ivb. Job performance Va. Number of friends * IIIb. Participation in VIId. (No) other school Vb. Contacts with friends organisations problems VIb. Behavior with other children VIc. Behavior with parents VIIb. (No) special class * Total social scale Total competence score * Sydney scored higher; i.e. reported to have more friends and less to attend a special class
48
Table 20. Mean Scores (SD) of the Melbourne Sample for Competence and Problem Scales (Taken from Bond et al. (1994)) 7-year-olds 12-year-olds 15-year-olds Boys (n = 333)
Girls (n = 231)
Boys (n = 181)
Girls (n = 69)
Boys (n = 122)
Girls (n = 73)
24.6 (15.4)
23.2 (17.0)
21.7 (16.8)
17.1 (16.0)
15.6 (15.0)
18.7 (17.0)
Internalising
6.4 (5.3)
7.6 (6.3)
6.9 (6.8)
6.3 (6.1)
5.2 (6.0)
7.5 (7.5)
Externalising
9.3 (6.6)
7.3 (6.3)
6.9 (6.8)
5.9 (6.5)
5.5 (5.4)
5.4 (5.4)
Competence score
17.9 (3.2)
18.4 (3.1)
19.3 (2.9)
19.6 (3.0)
18.8 (3.3)
18.5 (3.7)
Activities
6.9 (2.1)
7.3 (2.0)
7.6 (1.9)
7.6 (1.7)
6.9 (2.0)
7.0 (2.3)
Social
5.9 (1.7)
6.0 (1.7)
6.6 (1.7)
6.7 (2.0)
6.9 (1.9)
6.4 (1.8)
School
5.0 (0.8)
5.1 (0.7)
5.0 (0.8)
5.3 (0.5)
5.0 (0.7)
5.0 (1.0)
Problem score
Table 21. Comparison of Mean Scores of Melbourne Children (7-Years), Sydney Children (6- to 11-Years) and American Children (6- to 11-Years) by Gender (Taken from Bond et al. (1994)) Boys Girls Melbourne (n = 333)
Sydney (n = 300)
Problem score
24.6
32.4 (S>M)
Internalising
6.4
Externalising
USA (n = 458)
Melbourne (n = 231)
Sydney (n = 300)
24.3
23.2
30.6 (S>M)
23.1
8.5 (S>M)
5.6
7.6
9.0 (S>M)
6.3 (M>A)
9.3
12.4 (S>M)
9.8
7.3
10.4 (S>M)
8.2
Competence
17.9
19.2 (S>M)
18.6 (A>M)
18.4
20.0 (S>M)
18.7
Activities
6.9
7.6 (S>M)
6.6
7.3
8.3 (S>M)
6.4(M>A)
Social
5.9
6.5 (S>M)
7.5 (A>M)
6.0
6.3
6.9 (A>M)
School
5.0
4.9
4.8 (M>A)
5.1
5.3
5.3
S>M = Sydney > Melbourne, at p <.01 A>M = America > Melbourne, at p <.01 M >A = Melbourne > America, at p <.01
49
USA (n = 488)
Table 22. Comparison of Mean Scores of Melbourne Children (12- and 15-Years), Sydney Children (12- to 16-Years) and American Children (12- to 16-Years) by Gender (Taken from Bond et al. (1994)) Boys Girls Melbourne (n = 303)
Sydney (n = 250)
Problem score
19.3
27.7 (S>M)
Internalising
6.2
Externalising
USA (n = 564)
Melbourne (n = 142)
Sydney (n = 250)
22.5 (A>M)
17.9
29.8 (S>M)
22.0 (A>M)
8.1 (S>M)
6.3
6.9
10.2 (S>M)
7.5
6.7
10.3 (S>M)
8.2 (A>M)
5.6
9.7 (S>M)
7.1 (A>M)
Competence
19.1
19.0
19.0
19.1
19.4
19.1
Activities
7.3
7.4
6.6 (M>A)
7.3
7.9 (S>M)
6.5 (M>A)
Social
6.7
6.7
7.5 (A>M)
6.5
6.5
7.3 (A>M)
School
5.0
4.7
4.8 (M>A)
5.1
5.0
5.1
S>M = Sydney > Melbourne, at p <.01 A>M = America > Melbourne, at p <.01 M >A = Melbourne > America, at p <.01
50
USA (n = 604)
11.2
Appendix 2: Morbidity Studies in Select Populations – Associated Tables
Table 1. Scores of Males on the YSR (Taken from Goldney, et al. (1996) Community group Adoption group (n=116) (n=23) Mean SD Mean SD
Clinic group (n=68) Mean SD
Total score
35.8
21.5
30.8
18.4
61.5
28.4
Internalising
14.3
10.1
12.0
10.0
24.7
14.1
Externalising
12.8
8.8
10.1
7.3
22.3
11.4
Depressed
9.1
6.3
8.4
7.7
13.9
8.5
Unpopular
6.9
6.1
5.1
4.6
14.2
9.1
Somatic complaints
3.3
3.3
3.1
2.8
6.0
4.5
Self-destructive/Identity
1.8
2.2
1.0
1.5
3.8
3.4
Thought disorder
8.4
3.0
3.0
2.9
5.9
4.0
Aggressive
8.3
5.9
5.7
4.9
12.6
7.1
Delinquent
7.2
5.6
6.3
4.4
14.0
7.5
Table 2. Scores of Females on the YSR (Taken from Goldney, et al. (1996) Community group Adoption group (n=117) (n=11) Mean SD Mean SD
Clinic group (n=32) Mean SD
Total score
39.5
22.9
37.8
20.4
65.4
25.4
Internalising
18.8
12.1
17.4
10.0
32.8
15.1
Externalising
12.2
8.2
12.1
8.3
18.8
9.6
Depressed
13.9
10.0
13.7
8.8
24.4
11.4
Unpopular
3.0
2.6
3.0
2.9
6.8
3.9
Somatic complaints
5.4
3.7
4.3
2.4
9.5
6.1
Thought disorder
5.5
3.6
5.5
4.2
8.2
4.6
Aggressive
8.1
5.7
8.2
5.4
10.9
5.5
Delinquent
5.3
4.1
5.4
5.1
9.3
5.8
51
Table 3. Scores of Males on the CBCL (Taken from Goldney, et al. (1996)) Community group Adoption group (n=121) (n=23) Mean SD Mean SD
Clinic group (n=68) Mean SD
Total score
22.3
15.6
21.0
19.2
65.3
29.2
Internalising
9.5
7.5
9.3
10.5
25.9
13.8
Externalising
10.2
8.3
8.4
7.4
32.9
15.1
Somatic complaints
2.2
2.6
2.4
3.6
5.0
4.3
Schizoid
1.3
1.8
1.7
2.7
4.9
4.1
Uncommunicative
4.3
3.7
4.0
4.9
10.7
6.4
Immature
1.1
1.4
1.4
2.0
4.8
3.3
Obsessive-compulsive
1.7
1.6
1.3
1.4
4.3
3.6
Hostile-withdrawal
2.4
2.8
1.9
2.4
9.4
5.6
Delinquent
1.4
1.9
1.3
1.5
8.4
5.0
Aggressive
6.7
5.7
5.3
5.4
20.2
9.7
Hyperactive
3.9
3.2
3.5
3.2
9.5
5.5
Table 4. Scores of Females on the CBCL (Taken from Goldney, et al. (1996)) Community group Adoption group (n=120) (n=11) Mean SD Mean SD
Clinic group (n=32) Mean SD
Total score
22.7
16.9
26.0
21.5
58.6
31.4
Internalising
10.0
7.6
10.3
7.5
23.8
14.6
Externalising
9.8
9.6
11.9
14.1
29.3
15.6
Anxious-obsessive
4.8
4.1
4.6
3.3
12.3
8.2
Somatic complaints
1.4
1.7
1.4
1.9
4.1
3.6
Schizoid
1.1
1.3
1.9
2.0
2.8
2.7
Depressed-withdrawal
4.1
3.3
3.6
3.6
7.2
5.3
Immature-Hyperactive
3.0
2.9
3.6
4.6
9.3
6.8
Delinquent
3.6
3.9
5.9
8.8
9.1
8.0
Aggressive
6.3
5.9
5.4
5.3
12.8
9.8
Cruel
1.1
2.1
2.4
4.6
8.4
8.3
52
Table 5. Mean CBCL Scores for a Clinically Referred Melbourne Sample (Taken from Nolan (1996)) 4-11year olds 12-16 year olds Boys Girls Boys Girls Total (n=1342) (n=628) (n=246) (n=267) (n=201) Broad band scales Total behavior problems
66.9
64.5
68.5
66.0
66.7
Internalising problems
64.4
62.3
66.3
66.7
64.8
Externalising problems
64.5
60.7
66.5
62.2
63.8
Withdrawn
62.9
62.5
64.5
64.2
63.4
Somatic complaints
60.7
59.7
62.5
64.5
61.5
Anxious/depressed
65.0
62.7
66.9
65.8
65.1
Social problems
63.6
63.9
64.6
60.0
63.3
Thought problems
61.4
62.2
60.9
61.5
61.5
Attention problems
66.2
64.6
67.5
63.4
65.7
Delinquent behavior
63.9
61.0
65.6
63.5
63.6
Aggressive behavior
66.6
62.5
67.2
63.0
65.4
Total score
38.7
40.1
36.1
39.3
38.5
Activities
43.9
42.3
39.7
41.2
42.2
Social
38.1
39.4
34.1
38.1
37.4
School
40.3
40.3
40.2
41.5
40.5
Syndrome scale
Social Competence Scale
Table 6. Mean Raw Scores (SD) for the CBCL and YSR Total, Externalising, Internalising and Anxious/Depressed Scales and Prevalence (%) of DSM Diagnoses (adapted from Rey et al. (2002)) Depression instrument not Depression instrument used used (n = 909) (n = 401) CBCL Total Problems
63.12 (30.85)
63.12 (29.36)
Internalising
21.15 (10.94)
20.61 (10.88)
Externalising
24.35 (14.16)
20.88 (14.13)
Anxious/Depressed
11.48 (6.27)
11.24 (6.24)
Total Problems
62.96 (29.73)
62.84 (29.03)
Internalising
21.08 (12.13)
21.19 (12.29)
Externalising
18.80 (10.69)
18.50 (10.54)
Anxious/Depressed
11.74 (7.69)
12.11 (7.80)
YSR
53
Table 7. Measures of General Psychopathology of Inpatient Compared with Western Australian Normative Data (Adapted from Paterson (1997)) Psychiatric unit (n = 58)* WACHS (n = 1655) Mean
SD
% ‘cases’
Mean
SD
% ‘cases’
CBCL
75.29
7.92
93
46.66
10.71
10
TRF
66.70
11.52
77
48.35
10.01
12
YSR 58.70 12.21 51 51.12 10.07 CBCL, TRF and YSR sample sizes vary owing to teacher and child response rates
24
Table 8. Mean Scores on the CBCL and YSR of Children Assigned to One of Three Treatment Settings or Seen for Psychiatric Consultation Only (adapted from McDermott (2002) Inpatient care Day treatment Outpatient care Consultation only Symptom area (N = 126) (N = 68) (N = 250) (N = 130) Mean SD Mean SD Mean SD Mean SD CBCL Total problem score
72.55
8.33
73.20
8.52
64.58
10.54
66.64
11.40
Int.
72.11
9.90
68.84
11.37
63.44
10.63
63.88
12.53
Ext.
67.30
11.15
70.75
10.72
60.89
12.24
62.15
14.20
Total competency
35.70
8.39
33.56
7.76
39.27
8.99
39.41
9.45
Social
35.61
9.36
34.38
8.96
39.15
9.02
39.58
10.17
Activities
41.48
8.35
39.98
8.41
43.37
8.58
43.90
8.09
School
39.82
9.00
36.43
8.18
41.02
9.60
41.02
9.60
Total problem score
67.05
13.46
58.82
12.77
56.97
11.45
53.61
12.02
Int.
68.63
13.01
57.26
12.01
58.11
11.99
56.53
12.53
Ext.
59.79
13.14
59.41
13.87
53.75
11.96
51.00
11.70
Total competency
39.15
10.46
39.39
10.81
42.84
10.29
47.45
10.88
YSR
54
11.3
Appendix 3: Diagnostic Utility – Associated Tables
Table 1. Sensitivities (Upper) and Specificities (Lower) for CBCL Scores and DICA Classifications (Taken from Zubrick (1997) CBCL results Attention Anxious DICA results Total T ≥ 67 Delinquent Somatic problems /depressed Any diagnosis 0.83 0.67 ADHD 0.72 0.85 Conduct disorder 0.80 0.81 Dysthymia 0.88 0.81 Situation anxiety 0.75 0.69 Depression and anxiety 0.66 0.80 Somatisation 0.84 0.50 Table 2. Sensitivity and Specificity, Calculated Using the Referred and Non-Referred Melbourne Children (Taken from Nolan (1996)) Sensitivity Specificity Total behavior score (t ≥ 60)
77.4%
83.2%
Total behavior score (t ≥ 63)
70.49%
88.6%
Total social competence score
62.6%
69.5%
Table 3. Mean (SD) Self-Reported Anxiety and Mother CBCL Internalising Scores Across Groups (Taken from Cobham et al. (1999)) Anxious Child Child + Parent Clinical Non-clinical Total Measure Anxiety Anxiety Control Control (n = 33) (n = 17) (n = 16) (n = 20) (n = 20) RCMAS 16.1 (6.6) 15.9 (7.9) 16.3 (5.0) 8.6 (6.5) 9.6 (6.9) CBCL-Internalising
69.1 (8.6)
65.5 (8.5)
72.9 (7.1)
55
61.1 (10.8)
52.7 (9.7)
Table 4. Mean Scores (SD) on Self-Report and Parent-Report Measures (Taken from (Barrett et al., 2001)) Pre-treatment 1-year follow-up 6-year follow-up Measure CDI
CBT
CBT+FAM
CBT
CBT+FAM
CBT
CBT+FAM
6.94 (4.45)
2.35 (2.78)
3.06 (3.49)
8.00 (5.39)
6.75 (5.52)
122.94 (23.82)
99.65 (23.28)
88.88 (16.03)
108.54 (17.90)
95.94 (10.21)
11.75 (6.10)
4.40 (4.06)
4.75 (4.58)
8.16 (6.66)
6.31 (5.86)
70.22 (7.51)
66.00 (5.84)
50.19 (8.59)
50.11 (6.95)
50.44 (12.79)
55.56 (13.32)
68.20 (6.78)
64.79 (9.31)
51.30 (9.00)
47.00 (7.39)
49.75 (12.39)
53.43 (16.48)
59.22 (8.93)
54.94 (9.64)
45.67 (7.67)
47.67 (10.06)
46.22 (9.12)
45.06 (10.29)
9.92 (7.15)
FSSC-R
136.58 (22.96)
RCMAS
13.60 (5.74)
CBCL-I Mother Father CBCL-E Mother
Father 60.25 (8.30) 54.43 (7.64) 47.50 (8.04) 45.93 (9.89) 46.65 (11.43) 45.21 (13.22) CBT = Cognitive behavioral treatment; FAM = Family anxiety management; CBCL-I = Child Behavior Checklist Internalising; CBCL-E= Child Behavior Checklist Externalising Table 5. Sensitivity and Specificity of the CBCL Hyperactivity Subscale at a Selection of Cut-off Scores When Discriminating Between Adolescents With and Without DSM-III ADHD (Taken from Rey et al. (1992)) Cut-off Score Sensitivity Specificity 0
1.00
0.00
2
1.00
0.04
4
1.00
0.09
6
0.99
0.20
8
0.99
0.34
10
0.95
0.50
12
0.87
0.65
14
0.71
0.82
16
0.37
0.91
18
0.19
0.96
20
0.05
0.99
56
Table 6. Mean (SD) CBCL Scores for ADHD Subtypes and Controls (Taken from Graetz (2001)) Inattentive Hyper-Imp Combined Controls CBCL Scale Pairwise comparisons (I) (HI) (C) (N) 39.6 (25.2) 43.8 (26.9) 62.1 (27.2) 16.1 (16.0) C > HI & I > N Total problems Externalising
12.7 (9.4)
17.7 (10.0)
26.7 (11.2)
5.7 (6.4)
C > HI > I > N
Internalising
10.3 (9.5)
9.3 (9.0)
12.5 (8.8)
4.7 (5.5)
C, I & HI > N; C > HI
Withdrawn
3.6 (3.6)
2.9 (3.1)
3.9 (3.1)
1.4 (2.0)
C, HI & I > N
Somatic
2.0 (2.4)
1.8 (2.5)
2.2 (2.2)
1.2 (1.8)
C&I>N
Anxious/Depressed
5.3 (5.4)
5.0 (5.3)
7.1 (5.6)
2.3 (3.0)
C > I & HI > N
Social Problems
4.1 (3.5)
3.2 (3.5)
4.8 (3.1)
1.1 (1.7)
C & I > HI > N
Thought Problems
1.2 (1.8)
1.0 (1.4)
1.6 (2.1)
0.2 (0.7)
C > HI & I > N
Attention Problems
7.9 (4.3)
6.7 (4.1)
10.5 (3.9)
1.9 (2.6)
C > I > HI > N
Delinquent Behavior
2.9 (2.9)
3.9 (4.1)
6.4 (4.0)
1.2 (2.0)
C > HI > I > N
Aggressive Behavior
9.8 (7.0)
13.9 (6.7)
20.3 (8.3)
4.5 (4.9)
C > HI > I > N
Table 7. Factor Pattern Matrix Obtained After Rotation Between the 22 CBCL Items (Taken from (Rey & Morris-Yates, 1993)) Factor 1 Factor 2 Factor 3 Factor 4 No. Item content (Aggression) (Delinquency) (Oppositionality) (Escapism) CD items 95.
Temper
.586
68.
Screams a lot
.413
3.
Argues
.684
22.
Disobedient at home
.696
23.
Disobedient at school
.431
94.
Teases a lot Stubborn, sullen, irritable Swearing, obscene language ODD items
86. 90.
.498 .587 .418
82.
Steals outside home
.516
81.
Steals at home
.521
67.
Runs away from home
43.
Lying, cheating
72.
Sets fires
101.
Truancy, skips school
106.
Vandalism
.464
21.
Destroys others’ things
.452
.586 .476 .367 .485
57
15.
Cruel to animals
.434
37.
.491
16.
Gets in many fights Physically attacks people Cruelty, bullying
105.
Uses alcohol, drugs
97.
Threatens people
57.
.727 .635 .449 .681
Table 8. Mean CBCL and Axis V Scores (SD) for the ODD and CD Samples (Taken from Rey et al. (1988)) ODD CD (n = 25) (n = 42) CBCL social competence 36.6 (7.9) 31.6 (9.6) CBCL internalising
66.8 (6.5)
69.4 (7.3)
CBCL externalising
67.9 (7.1)
72.7 (7.5)
CBCL total score
69.4 (7.6)
74.9 (7.5)
DSM Axis V
4.7 (.69)
5.3 (0.8)
Table 9. CBCL Items of the Proposed Depression Subscale (Taken from Nurcombe et al. (1989)) Item-total Item Item content correlation 13. Confused or seems to be in a fog 0.45 14. Cries a lot 0.37 18. Deliberately harms self or attempt suicide 0.28 30. Fears going to school 0.30 31. Fears he/she might think or do something bad 0.49 32. Feels he/she has to be perfect 0.32 35. Feels worthless or inferior 0.49 42. Like to be alone 0.22 47. Nightmares 0.33 50. Too fearful or anxious 0.53 52. Feels too guilty 0.44 54. Overtired 0.46 56b. Headaches 0.34 75. Shy or timid 0.38 77. Sleeps more than most children during the day or night 0.37 80. Stares blankly 0.35 91. Talks about killing self 0.40 100. Trouble sleeping 0.40 102. Underactive, slow moving, or lacks energy 0.41 103. Unhappy, sad, or depressed 0.60 111. Withdrawn, doesn’t get involved with others 0.45 112. Worrying 0.48 58
Table 10. YSR-CDI and CBCL-YSR Scale Items (Taken from Hepperlin (1990)) Item No. 12. 103. 11. 35. 13. 33. 91. 87. 30. 14. 9. 18. 8. 100. 45.
Summary of item content Lonely Sad Worrying Feels worthless Confused Feels unloved Suicidal talk Moody Fears school Cries much Obsessions Harms self Can’t concentrate Can’t sleep Nervous
Table 11. Item Content of the Various Depression Scales (Taken from Rey and Morris-Yates (1991)) Scale Item no.
Item content
1
2
3
8
Can’t concentrate
+
9
Obsessions
+
+
+
12
Lonely
+
+
+
13
Confused
+
+
+
+
14
Cries a lot
+
+
17
Day dreams
18
Harms self or attempts suicide
24
Doesn’t eat well
+
27
Easily jealous
+
30
Fears going to school
+
31
Fears doing something bad
+
32
Feels has to be perfect
+
33
Feels unloved
34
Feels persecuted
35
Feels worthless
+
42
Likes to be alone
+
45
Nervous, tense
46
Nervous movements
47
Nightmares
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ +
+
59
+
+ +
+
+
5
+
+ +
4
48
Not liked
+
50
Too fearful or anxious
51
Feels dizzy
52
Feels too guilty
+
54
Overtired
+
56B
Headaches
+
62
Poorly coordinated
69
Secretive
+
71
Self-conscious
+
+
75
Shy or timid
+
+
+
77
Sleeps more
+
80
Stares blankly
+
86
Stubborn
87
Sudden changes in mood
89
Suspicious
91
Talks about killing self
+
100
Trouble sleeping
+
102
Underactive, lacks energy
+
103
Unhappy, sad or depressed
+
111
Withdrawn
+
+
+
+
+ + +
+
+ + +
+ +
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
112 Worrying + + + + + Note: 1: CBCL-NUR 2: YSR-CDI 3. YSR-DEPB 4. YSR-DEPG 5. Anxious/depressed (all items from the parent and child reports except items 18 and 19 from YSR only). Composite scale equals CBCL-NUR plus YSR-CDI divided by 2.
60
Table 12. Means and Standard Deviations of Depression Scores on the Proposed CBCL Depression Scale Among Diagnostic Groups (Taken from Rey and Morris-Yates (1992)) Group N Mean SD CBCL-NUR Major depression
23
22.5
7.7
All other disorder
634
14.0
8.4
Dysthymia
62
17.5
8.3
Separation anxiety
57
14.7
7.9
Major depression
24
19.5
7.0
All other disorder
635
11.4
6.8
Dysthymia
60
16.8
7.2
Separation anxiety
61
10.9
6.3
Major depression
14
24.9
9.4
All other disorder
368
14.5
7.7
Dysthymia
27
18.5
7.7
Separation anxiety
30
14.7
6.2
Major depression
10
37.3
11.4
All other disorder
261
26.4
13.2
Dysthymia
33
36.2
12.6
Separation anxiety
30
23.5
14.2
Major depression
23
21.0
6.1
All other disorder
627
12.9
6.3
Dysthymia
62
17.4
6.0
Separation anxiety
57
13.0
6.0
Major depression
24
35.0
10.0
All other disorder
623
22.3
10.9
Dysthymia
60
29.8
11.2
Separation anxiety
59
21.6
10.5
YSR-CDI
YSR-DEPB
YSR-DEPG
Composite
Anxious/Depressed
61
Table 13. Descriptive Statistics and Prevalence (%) of Disorders When Using the Selected Cut-off Points in the Australian and US Cohorts (Taken from (Rey, 1994)) Australian cohort
US cohort
Scale
Mean
SD
Prevalence
Mean
SD
Prevalence
Depression
14.44
8.07
20.3
10.39
6.83
7.5
Hyperactivity
9.51
4.85
20.8
8.24
4.27
10.5
Oppositionality
10.42
6.28
28.2
8.81
5.21
15.5
Conduct
4.34
4.06
21.1
3.32
2.98
10.1
Table 14. Odds Ratio Between Conduct (CD), Oppositional (ODD), Attention Deficit-Hyperactivity (ADHD) and Depressive (DEP) Disorders (95% Confidence Limits) (Taken from (Rey, 1994)) Australian cohort US cohort Disorders (n = 2092) (n = 484) ODD and CD
7.35 (5.85-9.25)
6.14 (3.14-12.00)
ADHD and CD
4.55 (3.61-5.73)
3.61 (1.67-7.75)
DEP and CD
1.20 (0.93-1.55)
1.45 (0.47-4.17)
ADHD and ODD
7.03 (5.60-8.33)
9.02 (4.62-17.67)
DEP and ODD
1.41 (1.12-1.78)
2.19 (0.94-5.01)
ADHD and DEP
1.67 (1.30-2.13)
2.22 (0.83-5.71)
62
11.4
Appendix 4: Stability of Behavioral and Emotional Problems – Associated Tables
Table 1. Correlation Coefficients for CBCL (5-Years)/CBCL (11- to 12-Years), CBCL (5-Years)/ YSR (11- to 12-Years) and CBCL (5-Years)/TRF (11- to 12-Years) (Taken from Sawyer (1996)) Variables correlated with CBCL completed at age 5 years CBCL YSR TRF (11- to 12-years) (11- to 12-years) (11- to 12-years) Total behavior problems .54 .19 .07 Internalising problems
.46
.15
.06
Externalising problems
.51
.22
.14
Withdrawn
.39
.11
.09
Somatic complaints
.31
.11
-.04
Anxious/depressed
.45
.12
.12
Social problems
.48
.06
.07
Thought problems
.24
.12
-.07
Attention problems
.46
.17
.16
Delinquent behavior
.29
.11
.05
Aggressive behavior
.54
.22
.15
Table 2. The Percentage of High Scoring (> 80th percentile) 5-Year-Old Children Who Had High (> 80th Percentile), Medium (50th to 80th Percentile) and Low (< 50th Percentile) Scores at the Age of 11- to 12-Years (Taken from Sawyer (1996)) Score at 11-12 years Mother report (%) Self report (%) Teacher report (%) Total problem scale (n = 56) High score
34
36
27
Medium score
55
30
37
Low score
11
34
36
High score
42
27
20
Medium score
31
26
36
Low score
27
47
44
High score
49
32
30
Medium score
28
32
45
Low score
23
36
25
Internalising (n = 55)
Externalising (n = 53)
63
Table 3. Odds ratios and 95% confidence limits for high scores on the CBCL at 11- to 12-years for high versus low scoring at 5-years (n = 277) (Taken from Sawyer (1996)) Odds ratio 95% confidence interval Broad band scale (>80 percentile) Total behavior problems
2.6
1.4-5.1
Internalising problems
3.8
2.0-7.3
Externalising problems
5.6
2.9-10.7
Withdrawn
5.0
2.0-12.5
Somatic complaints
3.7
1.5-8.9
Anxious/depressed
6.1
2.5-14.9
Social problems
15.7
6.6-37.7
Thought problems
2.8
1.2-6.6
Attention problems
5.5
2.2-13.8
Delinquent behavior
5.1
2.1-12.3
Aggressive behavior
9.3
3.6-24.0
Syndrome scale (>90 percentile)
64
11.5
Appendix 5: Cross Informant Stability – Associated Tables
Table 1. Mean Scores (±s.e.) from Mother, Father, Child and Teacher Reports (Taken from Sawyer et al. (1993, p 221)) Dimension
Mother score
Father score
Child Score
Teacher score
10-11 year old males (n = 86) Total Problems
22.5±2.0
20.0±2.1
29.3±2.0
18.0±2.3
Externalising
7.3±0.8
6.8±0.8
9.3±0.7
5.9±1.0
Internalising
6.7±0.6
5.6±0.6
8.3±0.6
3.5±0.5
10-11 year old females (n = 105) Total Problems 23.4±1.6
20.6±1.5
32.4±1.7
10.6±1.4
Externalising
7.1±0.6
6.4±0.5
7.9±0.5
2.1±0.4
Internalising
7.5±0.6
6.1±0.5
11.1±0.7
3.9±0.5
14-15 year old males (n = 71) Total Problems 21.2±2.0
20.4±2.2
33.6±2.6
17.9±2.7
Externalising
7.5±0.8
7.6±0.9
10.2±0.8
5.3±1.1
Internalising
6.2±0.7
5.9±0.7
10.5±1.0
4.7±0.8
14-15 year old females (n = 74) Total Problems 22.1±1.9
18.6±1.6
39.0±2.7
15.1±2.2
Externalising
7.3±0.8
6.5±0.7
11.1±0.9
4.9±0.9
Internalising
7.9±0.7
5.6±0.6
13.0±1.1
4.3±0.6
65
Table 2. Estimated Correlations* Between Scores Reported by Different Informants (Taken from Sawyer et al. (1993, p 221) Mother Father Child Teacher Total behavior problem score Mother
-
Father
0.74
-
Child
0.57
0.51
-
Teacher
0.46
0.43
0.27
-
Externalising scale Mother
-
Father
0.73
-
Child
0.58
0.48
-
Teacher
0.46
0.41
0.34
-
Internalising scale Mother
-
Father
0.66
-
Child
0.48
0.42
-
Teacher 0.30 0.23 0.23 * All correlations were significant at the level of p < .0001 Table 3. Prevalence (per 100) of Cases Identified by Different Informants (Taken from Sawyer (1992)) Mother report Father report Child report Teacher report 10-11 year old males Total problem scale 17.9±4.1 11.5±3.5 4.7±2.3 12.3±3.6 Externalising scale 11.3±3.5 7.3±2.9 3.6±2.0 11.9±3.6 Internalising scale 20.0±4.3 9.8±3.1 4.2±2.0 9.8±3.3 10-11 year old females Total problem scale Externalising scale Internalising scale
16.7±3.7 14.1±3.5 18.2±3.8
16.1±3.7 13.8±3.5 16.1±3.7
3.3±1.6 11.2±1.1 3.7±1.9
5.5±2.2 4.4±2.0 9.4±3.0
14-15 year old males Total problem scale Externalising scale Internalising scale
19.9±4.9 17.7±4.6 19.3±4.8
16.5±4.6 19.9±4.9 19.5±4.9
6.0±2.9 5.6±2.8 11.9±4.0
8.8±3.5 6.9±3.2 9.4±3.7
14-15 year old females Total problem scale Externalising scale Internalising scale
15.9±4.0 7.9±3.1 9.4±3.3
11.7±3.5 7.8±3.0 5.2±2.4
9.2±3.3 6.6±2.9 12.0±3.7
9.1±3.1 7.8±2.9 9.2±3.3
66
Table 4. The Percentage of Cases Identified When One, Two or Three Informants Were Employed For Case Identification (Taken from Sawyer (1992)) Total Informants Ext. (n = 68) Int. (n = 94) (n = 85) Mother 66 59 57 Father
54
56
45
Teacher
33
37
32
Child
22
19
27
Mother and father
85
78
74
Mother and teacher
77
74
76
Mother and child
74
66
72
Father and teacher
72
79
65
Father and child
64
69
63
Teacher and child
48
47
53
Mother, father and teacher
96
93
91
Mother, teacher and child
86
81
88
Mother, father and child
88
85
86
Father, teacher and child
80
88
81
67
Table 5. Mean (±SE) Parent, Teacher and Child Scores in the Community and Clinic Groups (Taken from Sawyer (1992)) Community group Clinic group Males Mother score (N = 41) (N = 68) Total behavior score
18.8±2.2
65.3±3.5
Externalising score
8.8±1.0
32.9±1.8
Internalising score
7.9±1.0
25.9±1.7
(N = 41)
(N = 68)
Total behavior score
14.8±1.7
59.7±3.5
Externalising score
7.0±1.0
31.2±1.9
Internalising score
8.4±1.0
23.5±1.6
(N = 41)
(N = 68)
Total behavior score
22.4±2.3
61.5±3.4
Externalising score
7.3±1.0
22.3±1.4
Internalising score
8.4±1.0
24.7±1.7
(N = 34)
(N = 57)
Total behavior score
13.7±2.1
57.5±4.1
Externalising score
10.7±2.5
40.9±3.2
Internalising score
2.8±0.6
12.8±1.3
(N = 41)
(N = 32)
Total behavior score
22.1±2.8
58.6±5.6
Externalising score
10.4±1.6
29.3±2.8
Internalising score
10.3±1.2
23.8±2.6
Father score Total behavior score Externalising score
(N = 42) 16.0±2.1 8.0±1.1
(N = 32) 63.3±4.7 31.9±2.5
Internalising score
7.2±1.0
25.1±2.1
(N = 42)
(N = 32)
Total behavior score
36.3±3.7
65.4±4.5
Externalising score
11.1±1.3
18.8±1.7
Internalising score
17.5±2.0
32.8±2.7
(N = 39)
(N = 26)
Total behavior score
9.2±1.8
48.4±6.8
Externalising score
5.7±1.5
32.8±5.3
Internalising score
2.6±0.5
11.3±2.0
Father score
Child score
Teacher score
Females Mother score
Child score
Teacher score
68
11.6
Appendix 6: Biopsychosocial factors and CBCL reports - Associated Tables
Table 1. Prevalence (± s.e.) of Cases in the Three School Groups (Taken from Sawyer et al. (1990)) All groups School group 1 School group 2 School group 3 US cut-off scores 10-11 year olds All children
21 ± 2.4
14.3 ± 3.8
15.8 ± 3.4
33.3 ±
Males
23.3 ± 3.5
9.1 ± 4.3
19.6 ± 5.6
42.1 ± 8.0
Females
19.4 ± 3.4
20.0 ± 6.3
12.7 ± 4.2
25.6 ± 6.7
All children
14.6 ± 2.2
10.3 ± 3.3
11.9 ± 3.5
23.1 ± 4.8
Males
14.2 ± 3.1
8.9 ± 4.2
13.9 ± 5.3
20.0 ± 6.3
Females
15.9 ± 3.3
11.9 ± 5.0
9.8 ± 4.6
26.3 ± 7.1
All children
9.2 ± 2.6
4.8 ± 2.3
8.8 ± 2.6
13.6 ± 3.8
Males
9.6 ± 2.5
2.3 ± 2.2
13.7 ± 4.8
13.1 ± 5.5
Females
8.7 ± 2.4
7.5 ± 4.2
4.8 ± 2.7
13.9 ± 5.3
All children
8.5 ± 1.8
6.9 ± 2.7
7.1 ± 2.8
11.5 ± 3.6
Males
7.8 ± 2.4
4.4 ± 3.1
9.3 ± 4.4
10.0 ± 4.7
Females
9.2 ± 2.6
9.5 ± 4.5
4.9 ± 3.4
13.2 ± 5.5
14-15 year olds
Sydney cut-off scores 10-11 year olds
14-15 year olds
Table 2. Association Between Low Family Income Over Time and Child Behavior Problems (Taken from Bor et al. (1997)) Low family income Externalising (%) SAT (%) Internalising (%) Never
8.2
9.5
9.5
Once
11.7
14.1
12.2
Twice
13.3
16.3
14.2
p < 0.01
p < 0.01
p < 0.01
Chi-squared
69
11.7
Appendix 7: Bibliography of Published Australian Studies Using the Achenbach System of Empirically Based Assessment (ASEBA)
11.7.1 Diagnoses Johnson, S., Barrett, P.M., Dadds, M.R., Fox, T., Shortt, A. The Diagnostic Interview Schedule for Children, Adolescents, and Parents: Initial reliability and validity data. Behaviour Change, 1999, 16, 155164. Rey, J.M., Plapp, J.M., Stewart, G., Richards, I., Bashir, M. Reliability of the psychosocial axis of DSMIII in an adolescent population. British Journal of Psychiatry, 1987, 150, 228-234. Rey, J.M., Stewart, G.W., Plapp, J.M., Bashir, M.R., Richards, I.N. Sources of unreliability of DSM-III Axis IV. Australia New Zealand Journal of Psychiatry, 1987, 21, 75-80. Rey, J.M., Stewart, G.W., Plapp, J.M., Bashir, M.R., Richards, I.N. Validity of axis V of DSM-III and other measures of adaptive functioning. Acta Psychiatrica Scandinavica, 1988, 77, 535-542.
11.7.2 Normative and Prevalence Studies Achenbach, T.M., Hensley, V.R., Phares, V., Grayson, D. Problems and competencies reported by parents of Australian and American children. Journal of Child Psychology & Psychiatry, 1990, 31, 265-286. Bond, L., Nolan, T., Adler, R., Robertson, C. The Child Behavior Checklist in a Melbourne urban sample. Australian Psychologist, 1994, 29, 103-109. Davies, L.C., McKelvey, R.S. Emotional and behavioural problems and competencies among immigrant and non-immigrant adolescents. Australia New Zealand Journal of Psychiatry, 1998, 32, 658-665. Garton, A.F., Zubrick, S.R., Silburn, S.R. The Western Australia Child Health Survey: A pilot study. Australia New Zealand Journal of Psychiatry, 1995, 29, 48-57. Goldney, R.D., Donald, M., Sawyer, M.G., Kosky, R.J., Priest, S. Emotional health of Indonesian adoptees living in Australian families. Australia New Zealand Journal of Psychiatry, 1996, 30, 534-539. Hensley, V.R. Australian normative study of the Achenbach Child Behavior Checklist. Australian Psychologist, 1988, 23, 371-382 Heubeck, B.G. Cross-cultural generalizability of CBCL syndromes across three continents: From the USA and Holland to Australia. Journal of Abnormal Child Psychology, 2000, 28, 439-450. Kovacs, G.T., Mushin, D., Kane, H., Baker, H.W.G. A controlled study of the psychosocial development of children conceived following insemination with donor semen. Human Reproduction, 1993, 8, 788-790. Najman, J.M., Bor, W., Andersen, M.J., O'Callaghan, M., Williams, G.M. Preschool children and behaviour problems. Childhood, 2000, 7, 439-466. 70
Nolan, T.M., Bond, L., Adler, R., Littlefield, L., Birleson, P., Marriage, K., Mawdsley, A., Salo, R., Tonge, B.J. Child Behaviour Checklist classification of behaviour disorder. Journal of Paediatrics and Child Health, 1996, 32, 405-411. Paterson, R., Bauer, P., McDonald, C.A., McDermott, B. A profile of children and adolescents in a psychiatric unit: Multidomain impairment and research implications. Australia New Zealand Journal of Psychiatry, 1997, 31, 682-690. Prior, M., Smart, D., Sanson, A., Oberklaid, F. Sex differences in psychological adjustment from infancy to 8 years. Journal of the American Academy of Child and Adolescent Psychiatry, 1993, 32, 291-304. Sawyer, M.G., Arney, F.M., Baghurst, P.A., Clark, J.J., Braetz, B.W., Kosky, R.J., Nurcombe, B., Patton, G.C., Prior, M.R., Raphael, B., Rey, J.M., Whaites, L.C., Zubrick, S.R. The mental health of young people in Australia: Key findings from the child and adolescent component of the national survey of mental health and well-being. Australia New Zealand Journal of Psychiatry, 2001, 35, 806-814. Sawyer, M.G., Kosky, R.J., Graetz, B.W., Arney, F., Zubrick, S.R., Baghurst, P. The National Survey of Mental Health and Wellbeing: the child and adolescent component. Australia New Zealand Journal of Psychiatry, 2000, 34, 214-220. Sawyer, M.G., Mudge, J., Carty, V., Baghurst, P., McMichael, A. A prospective study of childhood emotional and behavioural problems in Port Pirie, South Australia. Australia New Zealand Journal of Psychiatry, 1996, 30, 781-787. Sawyer, M.G., Sarris, A., Baghurst, P., Cornish, C.A., Kalucy, R.S. The prevalence of emotional and behavior disorders and patterns of service utilisation in children and adolescents. Australia New Zealand Journal of Psychiatry, 1990, 24, 323-330. Silburn, S.R., Zubrick, S.R., Garton, A., Gurrin, L., Burton, P., Dalby, R., Carlton, J., Shepherd, C., Lawrence, D. Western Australian Child Health Survey: Family and community health. Perth, WA: Australian Bureau of Statistics, 1996. Zubrick, S.R., Silburn, S.R., Garton, A., Burton, P., Dalby, R., Carlton, J., Shepherd, C., Lawrence, D. Western Australian Child Health Survey: Developing health and well-being in the Nineties. Perth, Western Australia: Australian Bureau of Statistics and the Institute for Child Health Research, 1995. Zubrick, S.R., Silburn, S.R., Gurrin, L., Teoh, H., Shepherd, C., Carlton, J., Lawrence, D. Western Australian child health survey: Education, health and competence. Perth, Western Australia: Australian Bureau of Statistics and the TVW Telethon Institute for Child Health Research, 1997. 11.7.3 Oppositional Defiance and Conduct Problems Gomez, R., Gomez, A., DeMello, L., Tallent, R. Perceived maternal control and support: Effects on hostile biased social information processing and aggression among clinic-referred children with high aggression. Journal of Child Psychology & Psychiatry, 2001, 42, 513-522. Lee, J.K.P., Jackson, H.J., Pattison, P., Ward, T. Developmental risk factors for sexual offending. Child Abuse & Neglect, 2002, 26, 73-92.
71
Little, E., Hudson, A., Wilks, R. Conduct problems across home and school. Behaviour Change, 2000, 17, 69-77. Martin, A.J., Linfoot, K., Stephenson, J. Exploring the cycle of mother-child relations, maternal confidence, and children's aggression. Australian Journal of Psychology, 2000, 52, 34-40. Luk, E.S.L., Staiger, P., Mathai, J., Field, D., Adler, R. Comparison of treatments of persistent conduct problems in primary school children: A preliminary evaluation of a modified cognitive-behavioral approach. Australia New Zealand Journal of Psychiatry, 1998, 32, 379-386. Luk, E.S.L., Staiger, P.K., Mathai, J., Wong, L., Birleson, P., Adler, R. Children with persistent conduct problems who drop out of treatment. European Child & Adolescent Psychiatry, 2001, 10, 28-36. Luk, E.S.L., Staiger, P.K., Wong, L., Mathai, J. Children who are cruel to animals: A revisit. Australia New Zealand Journal of Psychiatry, 1999, 33, 29-36. Rey, J.M., Bashir, M.R., Schwarz, M., Richards, I.N., Plapp, J.M., Stewart, G.W. Oppositional disorder: Fact or fiction? Journal of the American Academy of Child and Adolescent Psychiatry, 1988, 27, 157-162. Rey, J.M., Morris-Yates, A. Are oppositional and conduct disorders of adolescents separate conditions? Australia New Zealand Journal of Psychiatry, 1993, 27, 281-287. Rey, J.M., Plapp, J.M. Quality of perceived parenting in oppositional and conduct disordered adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 1990, 29, 382-385. Rey, J.M., Sawyer, M.G., Raphael, B., Patton, G.C., Lynskey, M. Mental health of teenagers who use cannabis. British Journal of Psychiatry, 2002, 180, 216-221.
11.7.4 Attention Problems and Hyperactivity Barnett, R., Maruff, P., Vance, A., Luk, E.S.L., Costin, J., Wood, C., Pantelis, C. Abnormal executive function in attention deficit hyperactivity disorder: The effect of stimulant medication and age on spatial working memory. Psychological Medicine, 2001, 31, 1107-1115. Doyle, S., Wallen, M., Whitmont, S. Motor skills in Australian children with attention deficit hyperactivity disorder. Occup Ther, 1995, 2, 229-240. Efron, D., Jarman, F., Barker, M. Side effects of methylphenidate and dexamphetamine in children with attention deficit hyperactivity disorder: A double-blind, crossover trial. Pediatrics, 1997, 100, 662-666. Graetz, B.W., Sawyer, M.G., Hazell, P.L., Arney, F., Baghurst, P. Validity of DSM-IV ADHD subtypes in a nationally representative sample of Australian children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 2001, 40, 1410-1417. Harrison, C., Sofronoff, K. ADHD and parental psychological distress: Role of demographics, child behavioral characteristics, and parental cognitions. Journal of the American Academy of Child and Adolescent Psychiatry, 2002, 41, 703-711. Hazell, P.L., Carr, V.J., Lewin, T.J., Dewis, S.A.M., Heathcote, D.M., Brucki, B.M. Effortful and automatic information processing in boys with ADHD and specific learning disorders. Journal of Child Psychology & Psychiatry, 1999, 40, 275-286. 72
Pailthorpe, W.K., Ralph, A. Time-out as a means of shaping whole-task completion as a precursor to establishing rule-following behaviour with a severely noncompliant preschool child. Behaviour Change, 1998, 15, 50-61. Rey, J.M., Walter, G., Plapp, J.M., Denshire, E. Family environment in attention deficit hyperactivity, oppositional defiant and conduct disorders. Australia New Zealand Journal of Psychiatry, 2000, 34, 453457. Sawyer, M.G., Rey, J.M., Graetz, B.W., Clark, J.J., Baghurst, P.A. Use of medication by young people with attention-deficit/hyperactivity disorder. MEDICAL JOURNAL OF AUSTRALIA, 2002, 177, 21-25. Sawyer, M.G., Whaites, L., Rey, J.M., Hazell, P.L., Graetz, B.W., Baghurst, P. Health-related quality of life of children and adolescents with mental disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 2002, 41, 530-537. Vance, A.L.A., Costin, J., Maruff, P. Attention Deficit Hyperactivity Disorder, combined typed (ADHDCT): Differences in blood pressure (BP) due to posture and the child report of anxiety. European Child & Adolescent Psychiatry, 2002, 11, 24-30.
11.7.5 Depression Hazell, P., Lewin, T. Friends of adolescent suicide attempters and completers. Journal of the American Academy of Child and Adolescent Psychiatry, 1993, 32, 76-81. Hepperlin, C.M., Stewart, G.W., Rey, J.M. Extraction of depression scores in adolescents from a general purpose behavior checklist. Journal of Affective Disorders, 1990, 18, 105-112. Martin, G., Clarke, M., Pearce, C. Adolescent suicide: Music preference as an indicator of vulnerability. Journal of the American Academy of Child and Adolescent Psychiatry, 1993, 32, 530-535. Martin, G., Waite, S. Parental bonding and vulnerability to adolescent suicide. Acta Psychiatrica Scandinavica, 1994, 89, 246-254. Price, I.R., Lavercombe, L.J. Depression in early adolescence: Relation to externalising and internalising behavior. Perceptual and Motor Skills, 2000, 90, 723-730. Rey, J.M. Comorbidity among disruptive disorders and depression in referred adolescents. Australia New Zealand Journal of Psychiatry, 1994, 28, 106-113. Rey, J.M., Bird, K.D. Sex differences in suicidal behavior of referred adolescents. British Journal of Psychiatry, 1991, 158, 776-781. Rey, J.M., Grayson, D., Mojarrad, T., Walter, G. Changes in the rate of diagnosis of major depression in adolescents following routine use of a depression rating scale. Australia New Zealand Journal of Psychiatry, 2002, 36, 229-233. Rey, J.M., Morris-Yates, A. Adolescent depression and the Child Behavior Checklist. Journal of the American Academy of Child and Adolescent Psychiatry, 1991, 30, 423-427.
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Rey, J.M., Morris-Yates, A. Diagnostic accuracy in adolescents of several depression rating scales extracted from a general purpose behavior checklist. Journal of Affective Disorders, 1992, 26, 7-16.
11.7.6 Delinquency and homelessness Adler, R., Nunn, R., Northam, E., Lebnan, V., Ross, R. Secondary prevention of childhood firesetting. Journal of the American Academy of Child and Adolescent Psychiatry, 1994, 33, 1194-1202. Dadds, M.R., Braddock, D., Cuers, S., Elliott, A., Kelly, A. Personal and family distress in homeless adolescents. Community Mental Health Journal, 1993, 29, 413-422. Efron, D., Sewell, J.R., Horn, M., Jewell, F. Children in homeless families in Melbourne: Health status and use of health services. Medical Journal of Australia, 1996, 165, 630-633. Kosky, R.J., Sawyer, M.G., Gowland, J.C. Adolescents in custody: Hidden psychological morbidity? Medical Journal of Australia , 1990, 153, 24-27. Sarris, A., Winefield, H.R., Cooper, C. Behaviour problems in adolescence: A comparison of juvenile offenders and adolescents referred to a mental health service. Australian Journal of Psychology, 2000, 52, 17-22.
11.7.7 Assessment Issues Najman, J.M., Williams, G.M., Nikles, J., Spence, S., Bor, W., O'Callaghan, M., LeBrocque, R., Andersen, M.J., Shuttlewood, G.J. Bias influencing maternal reports of child behaviour and emotional state. Social Psychiatry and Psychiatric Epidemiology, 2001, 36, 186-194. Najman, J.M., Williams, G.M., Nikles, J., Spence, S., Bor, W., O'Callaghan, M., LeBrocque, R., Andersen, M.J. Mothers' mental illness and child behavior problems: Cause-effect association or observation bias? Journal of the American Academy of Child and Adolescent Psychiatry, 2000, 39, 592602. Rey, J.M., Morris-Yates, A., Stanislaw, H. Measuring the accuracy of diagnostic tests using receiver operating characteristics (ROC) analysis. International Journal of Methods in Psychiatric Research, 1992, 2, 39-50. Rey, J.M., Schrader, E., Morris-Yates, A. Parent-child agreement on children's behaviours reported by the Child Behavior Checklist (CBCL). Journal of Adolescence, 1992, 15, 219-230. Sawyer, M., Sarris, A., Quigley, R., Baghurst, R., Kalucy, R. The attitude of parents to the use of computer assisted interviewing in a child psychiatry service. British Journal of Psychiatry, 1990, 157, 675-678. Sawyer, M.G., Baghurst, P., Clark, J. Differences between reports from children, parents, and teachers: Implications for epidemiological studies. Australia New Zealand Journal of Psychiatry, 1992, 26, 652660. 74
Sawyer, M.G., Baghurst, P., Mathias, J. Differences between informants' reports describing emotional and behavioral problems in community and clinic-referred children: A research note. Journal of Child Psychology & Psychiatry, 1992, 33, 441-449. Sawyer, M.G., Clark, J.J., Baghurst, P. Childhood emotional and behavioural problems: A comparison of children's reports with reports from parents and teachers. Journal of Paediatrics and Child Health, 1993, 29, 119-125. Sawyer, M.G., Sarris, A., Baghurst, P. The effect of computer assisted interviewing on the clinical assessment of children. Australia New Zealand Journal of Psychiatry, 1992, 26, 223-231. Sawyer, M.G., Sarris, A., Baghurst, P. The use of a computer-assisted interview to administer the Child Behavior Checklist in a child psychiatry service. Journal of the American Academy of Child and Adolescent Psychiatry, 1991, 30, 674-681. Sawyer, M.G., Streiner, D.L., Baghurst, P. The influence of distress on mothers' and fathers' reports of childhood emotional and behavioral problems. Journal of Abnormal Child Psychology, 1998, 26, 407414.
11.7.8 Neuropsychological Assessment Beardmore, S., Tate, R., Liddle, B. Does information and feedback improve children's knowledge and awareness of deficits after traumatic brain injury? Neuropsychological Rehabilitation, 1999, 9, 45-62. Blunden, S., Lushington, K., Kennedy, D., Martin, J., Dawson, D. Behavior and neurocognitive performance in children aged 5-10 years who snore compared to controls. Journal of Clinical and Experimental Neuropsychology, 2000, 22, 554-568. North, K., Hyman, S., Barton, B. Cognitive deficits in neurofibromatosis 1. Journal of Child Neurology, 2002, 17, 605-612. Pelco, L., Sawyer, M., Duffield, G., Prior, M., Kinsella, G. Premorbid emotional and behavioral adjustment in children with mild head injuries. Brain Injury, 1992, 6, 29-37. Ponsford, J., Willmott, C., Rothwell, A., Cameron, P., Ayton, G., Nelms, R., Curran, C., Ng, K. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics, 2001, 108, 12971303. Ponsford, J., Willmott, C., Rothwell, A., Cameron, P., Ayton, G., Nelms, R., Curran, C., Ng, K.T. Cognitive and behavioral outcome following mild traumatic head injury in children. Journal of Head Trauma Rehabilitation, 1999, 14, 360-372. Prior, M., Kinsella, G., Sawyer, M., Bryan, D., Anderson, V. Cognitive and psychosocial outcome after head injury in children. Australian Psychologist, 1994, 29, 116-123. Willmott, C., Anderson, V., Anderson, P. Attention following pediatric head injury: A developmental perspective. Developmental Neuropsychology, 2000, 17, 361-379.
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11.7.9 Anxiety Barrett, P.M. Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. Journal of Clinical Child Psychology, 1998, 27, 459-468. Barrett, P.M., Dadds, M., Rapee, R.M. Family treatment of childhood anxiety: A controlled trial. Journal of Consulting and Clinical Psychology, 1996, 64, 333-342. Barrett, P.M., Duffy, A.L., Dadds, M.R., Rapee, R.M. Cognitive-behavioral treatment of anxiety disorders in children: Long-term (6-year) follow-up. Journal of Consulting and Clinical Psychology, 2001, 69, 135-141. Barrett, P.M., Rapee, R.M., Dadds, M., Ryan, S.M. Family enhancement of cognitive style in anxious and aggressive children. Journal of Abnormal Child Psychology, 1996 , 24, 187-203. Barrett, P.M., Shortt, A.L., Fox, T.L., Wescombe, K. Examining the social validity of the FRIENDS treatment program for anxious children. Behaviour Change, 2001, 18, 63-77. Barrett, S., Heubeck, B.G. Relationships between school hassles and uplifts and anxiety and conduct problems in grades 3 and 4. Journal of Applied Developmental Psychology, 2000, 21, 537-554. Cobham, V.E., Dadds, M.R., Spence, S.H. Anxious children and their parents: What do they expect? Journal of Clinical Child Psychology, 1999, 28, 220-231. Cobham, V.E., Dadds, M.R., Spence, S.H. The role of parental anxiety in the treatment of childhood anxiety. Journal of Consulting and Clinical Psychology, 1998, 66, 893-905. Dadds, M., Spence, S.H., Holland, D., Barrett, P., Laurens, K. Prevention and early intervention for anxiety disorders: A controlled trial. Journal of Consulting and Clinical Psychology, 1997, 65, 627-635. Dadds, M.R., Holland, D.E., Laurens, K.R., Mullins, M., Barrett, P.M., Spence, S.H. Early intervention and prevention of anxiety disorders in children: Results at 2-year follow-up. Journal of Consulting and Clinical Psychology, 1999, 67, 145-150. Heyne, D., King, N.J., Tonge, B.J., Rollings, S., Young, D., Pritchard, M., Ollendick, T.H. Evaluation of child therapy and caregiver training in the treatment of school refusal. Journal of the American Academy of Child and Adolescent Psychiatry, 2002, 41, 687-695. Hudson, J.L., Rapee, R.M. Parent-child interactions in clinically anxious children and their siblings. Journal of Clinical Child and Adolescent Psychology, 2002, 31, 548-555. Hudson, J.L., Rapee, R.M. Parent-child interactions and anxiety disorders: An observational study. Behaviour Research and Therapy, 2001, 39, 1411-1427. King, N.J., Heyne, D., Tonge, B., Gullone, E., Ollendick, T.H. School refusal: Categorical diagnoses, functional analysis and treatment planning. Clinical Psychology and Psychotherapy, 2001, 8, 352-360. King, N.J., Tonge, B.J., Heyne, D., Pritchard, M., Rollings, S., Young, D., Myerson, N., Ollendick, T.H. Cognitive-behavioral treatment of school-refusing children: A controlled evaluation. Journal of the American Academy of Child and Adolescent Psychiatry, 1998, 37, 395-403. 76
Sawyer, M.G., Slocombe, C., Kosky, R., Clark, J., Mathias, J., Burfield, S., Faranda, I., Hambly, H., Mahar, A., Tang, B.N., Baghurst, P. The psychological adjustment of offspring of adults with obsessivecompulsive disorder: A brief report. Australia New Zealand Journal of Psychiatry, 1992, 26, 479-484. Shortt, A.L., Barrett, P.M., Dadds, M.R., Fox, T.L. The influence of family and experimental context on cognition in anxious children. Journal of Abnormal Child Psychology, 2001, 29, 585-596. Spence, S.H., Najman, J.M., Bor, W., O'Callaghan, M.J., Williams, G.M. Maternal anxiety and depression, poverty and marital relationship factors during early childhood as predictors of anxiety and depressive symptoms in adolescence . Journal of Child Psychology & Psychiatry, 2002, 43, 457-469. Spence, S.H., Rapee, R., McDonald, C., Ingram, M. The structure of anxiety symptoms among preschoolers. Behaviour Research and Therapy, 2001, 39, 1293-1316. Vance, A.L.A., Luk, E.S.L., Costin, J., Tonge, B.J., Pantelis, C. Attention deficit hyperactivity disorder: Anxiety phenomena in children treated with psychostimulant medication for 6 months or more. Australia New Zealand Journal of Psychiatry, 1999, 33, 399-406. Waters, A.M., Lipp, O.V., Cobham, V.E. Investigation of threat-related attentional bias in anxious children using the startle eyeblink modification paradigm. Journal of Psychophysiology, 2000, 14, 142150. Wever, C., Rey, J. Juvenile obsessive-compulsive disorder. Australia New Zealand Journal of Psychiatry, 1997, 31, 105-113.
11.7.10 Psychosocial Factors Barrett, P.M., Moore, A.F., Sonderegger, R. The FRIENDS program for young former-Yugoslavian refugees in Australia: A pilot study. Behaviour Change, 2000, 17, 124-133. Bor, W., Najman, J.M., Andersen, M.J., O'Callaghan, M., Williams, G.M., Behrens, B.C. The relationship between low family income and psychological disturbance in young children: An Australian longitudinal study. Australia New Zealand Journal of Psychiatry, 1997, 31, 664-675. Hoeltje, C.O., Zubrick, S.R., Silburn, S.R., Garton, A.F. Generalized self-efficacy: Family and adjustment correlates. Journal of Clinical Child Psychology, 1996, 25, 446-453. Burns, J.M., Baghurst, P.A., Sawyer, M.G., McMichael, A.J., Tong, S. Lifetime low-level exposure to environmental lead and children's emotional and behavioral development at ages 11-13 years. American Journal of Epidemiology, 1999, 149, 740-749. Mathias, J.L., Mertin, P., Murray, A. The psychological functioning of children from backgrounds of domestic violence. Australian Psychologist, 1995, 30, 47-56. Najman, J.M., Behrens, B., Andersen, M.J., Bor, W., O'Callaghan, M.J., Williams, G. Impact of family type and family quality on child behavior problems: A longitudinal study. Journal of the American Academy of Child and Adolescent Psychiatry, 1997, 36, 1357-1365. 77
Smith, J., Berthelsen, D., O'Connor, I. Child adjustment in high conflict families. Child: Care Health Dev, 1997, 23, 113-133. Williams, G.M., O'Callaghan, M., Najman, J.M., Bor, W., Andersen, M.J., Richards, D., U, C. Maternal cigarette smoking and child psychiatric morbidity: A longitudinal study. Pediatrics, 1998, 102, E111E118.
11.7.11 Physical Illness Anderson, V., Smibert, E., Ekert, T., Godber, T. Intellectual, educational, and behavioral sequelae after cranial irradiation and chemotherapy. Archives of Disease in Childhood, 1994, 70, 476-482. Catto-Smith, A.G., Nolan, T.M., Coffey, C.M.M. Inflammatory bowel disease. Clinical significance of anismus in encopresis. Journal of Gastroenterology and Hepatology, 1998, 13, 955-960. Davis, N.M., Doyle, L.W., Ford, G.W., Keir, E., Michael, J., Rickards, A.L., Kelly, E.A., Callanan, C. Auditory function at 14 years of age of very-low-birthweight children. Developmental Medicine and Child Neurology, 2001, 43, 191-196. Forbes, D., Withers, G., Silburn, S., McKelvey, R. Psychological and social characteristics and precipitants of vomiting in children with cyclic vomiting syndrome. Digestive Diseases and Sciences, 1999, 44, 19S-22S. Graetz, B.W., Shute, R.H., Sawyer, M.G. An Australian study of adolescents with cystic fibrosis: Perceived supportive and nonsupportive behaviors from families and friends and psychological adjustment. Journal of Adolescence Health, 2000, 26, 64-69. Grimwood, K., Nolan, T.M., Bond, L., Anderson, V.A., Catroppa, D., Keir, E.H. Risk factors for adverse outcomes of bacterial meningitis. Journal of Paediatrics and Child Health, 1996, 32, 457-462. Hutton, C.J., Bradley, B.J. Effects of Sudden Infant Death on bereaved siblings: A comparative study. Journal of Child Psychology & Psychiatry, 1994, 35, 723-732. Miller, M., Bowen, J.R., Gibson, F.L., Hand, P.J., Ungerer, J.A. Behaviour problems in extremely low birthweight children at 5 and 8 years of age. Child Care Health and Development, 2001, 27, 569-581. Nolan, T., Catto-Smith, T., Coffey, C., Wells, J. Randomised controlled trial of biofeedback training in persistent encopresis with anismus. Archives of Disease in Childhood, 1998, 79, 131-135. Nolan, T., Debelle, G., Oberklaid, F., Coffey, C. Randomized trial of laxatives in the treatment of childhood encopresis. Lancet, 1991, 338, 523-527. Northam, E., Anderson, P., Adler, R., Werther, G., Warne, G. Psychosocial and family functioning in children with insulin-dependent diabetes at diagnosis and one year later. Journal of Pediatric Psychology, 1996, 21, 699-717. Northam, E., Bowden, S., Anderson, V., Court, J. Neuropsychological functioning in adolescents with diabetes. Journal of Clinical and Experimental Neuropsychology, 1992, 14, 884-900. 78
Oates, R.K., Turnbull, J.A.B., Simpson, J.M., Cartmill, T.B. Parent and teacher perceptions of child behaviour following cardiac surgery. Acta Pediatric, 1994, 83, 1303-1307. O'Callaghan, M.J., Williams, G.M., Andersen, M.J., Bor, W., Najman, J.M. Prediction of obesity in children at 5 years: A cohort study. Journal of Paediatrics and Child Health, 1997, 33, 311-316. O'Callaghan, M.J., Williams, G.M., Andersen, M.J., Najman, J.M. Obstetric and perinatal factors as predictors of child behaviour at 5 years. Journal of Paediatrics and Child Health, 1997, 33, 497-503. Rickards, A.L., Kelly, E.A., Doyle, L.W., Callanan, C. Cognition, academic progress, behavior and selfconcept at 14 years of very low birth weight children. Journal of Developmental and Behavioral Pedatrics, 2001, 22, 11-18. Rowe, K.S. Double-blind randomized controlled trial to assess the efficacy of intravenous gammaglobulin for the management of chronic fatigue syndrome in adolescents. Journal of Psychiatric Research, 1997, 31, 133-147. Sabaz, M., Cairns, D.R., Lawson, J.A., Bleasel, A.F., Bye, A.M.E. The health-related quality of life of children with refractory epilepsy: A comparison of those with and without intellectual disability. Epilepsia, 2001, 42, 621-628 . Sabaz, M., Cairns, D.R., Lawson, J.A., Nheu, N., Bleasel, A.F., Bye, A.M.E. Validation of a new quality of life measure for children with epilepsy. Epilepsia, 2000, 41, 765-774. Sanders, M.R., Turner, K., Wall, C.R., Waugh, L.M., Tully, L.A. Mealtime behavior and parent-child interaction: A comparison of children with cystic fibrosis, children with feeding problems, and nonclinic controls. Journal of Pediatric Psychology, 1997, 22, 881-899. Sawyer, M., Antoniou, G., Toogood, I., Rice, M., Baghurst, P. Childhood cancer: A 4-year prospective study of the psychological adjustment of children and parents. Journal of Pediatric Hematology Oncology, 2000, 22, 214-220. Sawyer, M., Crettenden, A., Toogood, I. Psychological adjustment of families of children and adolescents treated for leukemia. American Journal of Pediatric Hematology Oncology, 1986, 8, 200-207. Sawyer, M.G., Antoniou, G., Toogood, I., Rice, M. Childhood cancer: A two-year prospective study of the psychological adjustment of children and parents. Journal of the American Academy of Child and Adolescent Psychiatry, 1997, 36, 1736-1743. Sawyer, M.G., Davidson, G.P., Goodwin, D., Crettenden, A.D. Recurrent abdominal pain in childhood. Adjustment of children and families: A preliminary study. Australian Paediatric Journal, 1987, 23, 121124. Sawyer, M.G., Macmullin, C., Graetz, B., Said, J.A., Clark, J.J., Baghurst, P. Social skills training for primary school children: A 1-year follow-up study. Journal of Paediatrics and Child Health, 1997, 33, 378-383. Sawyer, M.G., Streiner, D.L., Antoniou, G., Toogood, I., Rice, M. Influence of parental and family adjustment on the later psychological adjustment of children treated for cancer. Journal of the American Academy of Child and Adolescent Psychiatry, 1998, 37, 815-822. 79
Sawyer, M.G., Toogood, I., Rice, M., Haskell, C., Baghurst, P. School performance and psychological adjustment of children treated for leukemia: A long-term follow-up. Am Journal of Pediatric Hematology Oncology, 1989, 2, 146-152. Turner, K.M.T., Sanders, M.R., Wall, C.R. Behavioural parent training versus dietary education in the treatment of children with persistent feeding difficulties. Behaviour Change, 1994, 11, 242-258. Withers, G.D., Forbes, D.A. Precipitants and aetiology of cyclic vomiting syndrome. Acta Paediatr, 1998, 87, 272-277.
11.7.12 Sexual Abuse Buist, A., Janson, H. Childhood sexual abuse, parenting and postpartum depression--a 3-year follow-up study. Child Abuse & Neglect, 2001, 25, 909-921. Oates, R.K., O'Toole, B.I., Lynch, D.L., Stern, A., Cooney, G. Stability and change in outcomes for sexually abused children. Journal of the American Academy of Child and Adolescent Psychiatry, 1994, 33, 945-953. Oates, R.K., Tebbutt, J., Swanston, H., Lynch, D.L. Prior childhood sexual abuse in mothers of sexually abused children. Child Abuse & Neglect, 1998, 22, 1113-1118. Stern, A.E., Lynch, D.L., Oates, R., Toole, B.I., Cooney, G. Self esteem, depression, behaviour and family functioning in sexually abused children. Journal of Child Psychology & Psychiatry, 1995, 36, 1077-1089. Swanston, H.Y., Tebbutt, J.S., O'Toole, B.I., Oates, K. Sexually abused children 5 years after presentation: A case-control study. Pediatrics, 1997, 100, 600-608. Tong, L., Oates, K., McDowell, M. Personality development following sexual abuse. Child Abuse & Neglect, 1987, 11, 371-383.
11.7.13 Other Allen, K., Prior, M. Assessment of the validity of easy and difficult temperament through observed mother-child behaviors. International Journal of Behavioral Development, 1995, 18, 609-630. Barrett, P., Turner, C., Rombouts, S., Duffy, A. Reciprocal skills training in the treatment of externalizing behaviour disorders in childhood: A preliminary investigation. Behaviour Change, 2000, 17, 221-234. Crisp, S.R.J., O'Donnell M.J., Kingston L., Poot A., Thomas N.E. Innovative multi-modal day-patient treatment for severely disordered at risk adolescents. International perspectives on child and adolescent mental health. United Kingdom: Elsevier Science Ltd., 2000, Volume I, 331-345. Fotheringham, M.J., Sawyer, M.G. Do adolescents know where to find help for mental health problems? A brief report. Journal of Paediatrics and Child Health, 1995, 31, 41-43.
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Hemphill, S.A., Littlefield, L. Evaluation of a short-term group therapy program for children with behavior problems and their parents. Behaviour Research and Therapy, 2001, 39, 823-841. Heubeck, B., O'Sullivan, C. An exploration into the nature, frequency and impact of school hassles in the middle school years. Australian Psychologist, 1998, 33, 130-137. McDermott, B.M., Cvitanovich, A. Posttraumatic stress disorder and emotional problems in children following motor vehicle accidents: An extended case series. Australia New Zealand Journal of Psychiatry, 2000, 34, 446-452. McDermott, B.M., McKelvey, R., Roberts, L., Davies, L. Severity of children's psychopathology and impairment and its relationship to treatment setting. Psychiatric Services, 2002, 53, 57-62. Passmore, A., French, D. A model of leisure and mental health in Australian adolescents. Behaviour Change, 2000, 17, 208-220. Price, C.S., Spence, S.H., Sheffield, J., Donovan, C. The development and psychometric properties of a measure of social and adaptive functioning for children and adolescents. Journal of Clinical Child and Adolescent Psychology, 2002, 31, 111-122. Rey, J.M., Singh, M., Morris-Yates, A., Andrews, G. Referred adolescents as young adults: The relationship between psychosocial functioning and personality disorder. Australia New Zealand Journal of Psychiatry, 1997, 31, 219-226. Sanderson, J.A., Siegal, M. Loneliness and stable friendship in rejected and nonrejected preschoolers. Applied Developmental Psychology, 1995, 16, 571-583. Woods, S., Shearsby, J., Onslow, M., Burnham, D. Psychological impact of the Lidcombe Program of early stuttering intervention. International Journal of Language Communication Disorders, 2002, 37, 3140.
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