Rescorla-2005-Mental Retardation and Developmental Disabilities Research Reviews

MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES
RESEARCH REVIEWS 11: 226–237 (2005)
ASSESSMENT OF YOUNG CHILDREN USING THE
ACHENBACH SYSTEM OF EMPIRICALLY BASED
ASSESSMENT (ASEBA)
Leslie A. Rescorla*
Department of Psychology, Bryn Mawr College, Bryn Mawr, Pennsylvania
After providing a brief review of three other approaches to assessment of preschool children (DSM-IV diagnoses, “Zero to Three” diagnoses,
and temperament scales), this paper focuses on the Achenbach System of
Empirically Based Assessment (ASEBA). The empirically based assessment
paradigm provides user-friendly, cost-effective, reliable, and valid procedures for assessing children’s behavioral/emotional problems from the perspectives of multiple informants. The ASEBA preschool forms, the Child
Behavior Checklist for ages 1.5–5 (CBCL/1.5–5) and the Caregiver–Teacher
Report Form (C–TRF), are usable by many different kinds of professionals in
diverse settings. The CBCL/1.5–5 also includes the Language Development
Survey (LDS), which provides a quick screen for delays in vocabulary and
word combinations. The problem items of the CBCL/1.5–5 and the C–TRF
are scored on both empirically based syndromes and DSM-oriented scales,
which are normed on the same general population sample. Variations in
children’s functioning across contexts and interaction partners make it essential to obtain and integrate data from multiple sources. Therefore,
ASEBA software provides side-by-side comparisons of item and scale scores
from up to eight assessment forms per child. Clinical and research applications of ASEBA preschool forms are summarized in the paper, and strengths
© 2005 Wiley-Liss, Inc.
and limitations are discussed.
MRDD Research Reviews 2005;11:226 –237.
Key Words: CBCL/1.5–5; empirically based assessment; preschool assessment
T
his paper describes use of the Child Behavior Checklist
for Ages 1.5–5 (CBCL/1.5–5) and the Caregiver–
Teacher Report Form (C–TRF) [Achenbach and Rescorla, 2000] to assess behavioral and emotional problems in
young children. The CBCL/1.5–5 is a revision of the CBCL/
2–3 [Achenbach et al., 1987; Achenbach, 1992]; and the
C–TRF for ages 1.5–5 is a revision of the C–TRF/2–5 [Achenbach, 1997]. The CBCL/1.5–5 and the C–TRF are components of the Achenbach System of Empirically Based Assessment
(ASEBA); a comprehensive approach to the assessment of individuals from 18 months to 90⫹ years of age [Achenbach and
Rescorla, 2000, 2001, 2002; Achenbach et al., 2004]. When the
first ASEBA forms for preschool children were published in the
1980s; they were based on more than two decades of research on
parallel forms for school-age children [Achenbach, 1966, 1991;
Achenbach and Edelbrock, 1981]. Norms for the 2000 versions
of the CBCL/1.5–5 and the C–TRF were based on data collected as part of the 1999 National Survey of Children, Youth,
and Adults [Achenbach and Rescorla, 2000].
© 2005 Wiley-Liss, Inc.
Central features of the ASEBA include (a) assessment of
behavioral and emotional problems with user-friendly forms, (b)
profiles of scores on statistically derived, empirically based syndromes, (c) profiles of scores on DSM-oriented scales, (d) norms
by age and gender based on national probability samples, (e)
systematic comparison of ratings from multiple informants, and
(f) scores on Internalizing, Externalizing, and Total Problems
scales. Research conducted on ASEBA forms by scholars around
the world has yielded more than 5,500 published reports. Although most ASEBA research has focused on school-age children and adolescents, there are more than 200 published studies
of the ASEBA preschool forms [Bérubé and Achenbach, 2005].
APPROACHES TO ASSESSMENT OF YOUNG
CHILDREN
Assessment of young children’s emotional and behavioral
problems utilizes many different procedures. These include obtaining information from parents and caregivers via structured or
semi-structured interviews, written questionnaires, and rating
forms; observing the child in naturalistic or quasi-naturalistic
interaction with caregivers or peers; and conducting child interviews using verbal and play-based procedures. Most assessments use a combination of such methods. However the information is obtained, the professional must summarize the data
using some descriptive system. For structured assessment tools
such as behavior checklists, item ratings are easily summarized
via scores on scales. Professionals summarize data from naturalistic observations and from clinical interviews by writing narrative reports, by rating the child on a list of dimensions/characteristics, by coding discrete behaviors, or by evaluating the
presence/absence of symptoms for different diagnoses.
DSM Diagnoses
One of the most common ways to assess young children is
to make psychiatric diagnoses using the American Psychiatric
*Correspondence to: Leslie A. Rescorla, Ph.D., Professor of Psychology and
Director of Child Study Institute, Department of Psychology, Bryn Mawr College, 101 North Merion Avenue, Bryn Mawr, PA 19010-2988. E-mail:
[email protected]
Received 11 July 2005; Accepted 12 July 2005
Published online in Wiley InterScience (www.interscience.wiley.com).
DOI: 10.1002/mrdd.20071
Association’s [1994] Diagnostic and Statistical Manual (DSM-IV). Concepts of
childhood disorders have often been
shaped by adult diagnostic categories,
many of which originated in the 19th
century (e.g. schizophrenia, bipolar disorder). For many disorders, such as depression, children are diagnosed using the
adult categories and criteria, with little
modification. One of the first diagnostic
categories specific to very young children
was early infantile autism [Kanner, 1943].
The DSM-IV includes five Pervasive
Developmental Disorder (PDD) or “autism spectrum” diagnoses (Autistic Disorder, Asperger’s Disorder, Childhood
Integrative Disorder, Rett’s Disorder,
and Pervasive Developmental Disorder
NOS). Other DSM-IV diagnoses that are
commonly used for young children include Attention Deficit/Hyperactivity
Disorder (ADHD), Oppositional Defiant
Disorder, Separation Anxiety Disorder,
Specific Phobia, Generalized Anxiety Disorder, Selective Mutism, Major Depressive
Disorder, Reactive Attachment Disorder,
Feeding/Eating Disorders, and Elimination
Disorders. Recently, Bipolar Disorder has
become an accepted diagnosis for young
children.
In their review of psychiatric diagnoses for preschool children, Angold and
Egger [2004] suggest that research on
psychiatric disorders in preschoolers is
about 30 years behind such research on
older children and adolescents. They indicate that only a few epidemiological
studies of DSM diagnoses in preschoolers
have been published [Earls, 1982; Shaw
et al., 1997; Lavigne et al., 1998; Keenan
and Wackschlag, 2000]. Most of the
studies had small samples, low response
rates, and incomplete reports of findings.
Diagnostic procedures varied widely
across the studies, as did prevalence rates.
Across the three community studies cited
by Angold and Egger [2004], prevalence
rates ranged from 14 to 26% for any Axis
I diagnosis. Comorbidity between internalizing and externalizing disorders was
high when it was reported. Structured
diagnostic interviews have not been validated for preschoolers. Nonetheless, Angold and Egger [2004] conclude that “instruments and nosologies designed and
tested for use with older children appear
to be applicable to younger children,”
and that prevalence rates for the presence
of any diagnosis appear to be “rather similar” to those found for older children
and adolescents.
Epidemiological studies of DSM-IV
disorders in large general population samples of preschool children using well-specified, uniform diagnostic procedures are
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sorely needed. Although DSM-IV disorders such as ADHD and PDD have been
widely researched with young children,
systematic epidemiological research is lacking on the prevalence, patterning, and discriminative power of the symptoms that
the DSM-IV uses to define most disorders
in this age group.
Zero to Three Classification System
Dissatisfaction with the DSM-IV
approach led to the development of the
Zero to Three Diagnostic Classification of
Early Mental Disorders (DC: 0 –3). [Zero
to Three: National Center for Infants,
Toddlers, and Families, 1994]. The categories of the DC: 0 –3 were based on
expert consensus and distillations from
224 case reports [Lieberman et al., 2004].
Five axes are assessed in this multiaxial
system. First, a primary diagnosis is made
using the general categories of Traumatic
Stress Disorder, Disorder of Affect (including anxiety, bereavement/grief, depression, mixed, reactive attachment, and
gender identity), Adjustment Disorder,
Regulatory Disorder (hypersensitive, underreactive, motorically disorganized/
impulsive, or other), Sleep Behavior Disorder, Eating Behavior Disorder, or
Disorder of Relating and Communicating (PDD-type problems). Second, a Relationship Disorder Classification can be
made using one of six categories (overinvolved, underinvolved, anxious/tense,
angry/hostile, mixed, or abusive). Axis
III deals with Medical and Developmental Disorders/Conditions, including
DSM-IV diagnoses. Axis IV assesses Psychosocial Stressors, and Axis V measures
Functional, Emotional Developmental
Level (5-level scale).
In their review chapter, Angold
and Egger [2004] noted that the DC: 0 –3
has been used in only a few research
studies. Some of these studies [Dunitz et
al., 1996; Thomas and Guskin, 2001]
have demonstrated partial but not complete overlap between the DSM-IV and
the DC: 0 –3 systems. That is, in clinical
samples of preschoolers, some children
received comparable diagnoses in both
systems (PTSD, Anxiety Disorder, Adjustment Disorder), but others received
different diagnoses in the two systems
(e.g., Regulatory Disorder in DC: 0 –3,
but Oppositional Defiant Disorder or
Adjustment Disorder in DSM-IV). This
raises the issue of whether Regulatory
Disorder is a useful separate category, or
whether symptoms associated with Regulatory Disorder should be incorporated
into DSM criteria for various diagnoses.
Reliability and validity data on the
DC: 0 –3 are limited. Lieberman et al.
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[2004] described an unpublished report
[Barnard et al., 2002] that involved eight
clinical cases. A primary clinician assessed
each case using a commonly agreedupon protocol. Raw data from each case
(interviews, observations, and test scores)
were then reviewed by the team and a
consensus was reached for both DC: 0 –3
and DSM-IV diagnoses. The clinicians
apparently agreed that the DC: 0 –3 primary diagnosis was a better fit to the
child than the DSM-IV diagnosis. Five of
the eight cases received a DC: 0 –3 diagnosis of Regulatory Disorder; while four
of the eight received an Axis II diagnosis
of parent– child relationship problem.
The raters concluded that the DC: 0 –3
diagnosis was “always validated” by the
reported history, observations of the
child during play or snack time, symptom
screening tests, and parent– child interaction observations, a fact that Lieberman
et al., [2004] presented as an “important
finding.”
The DC: 0 –3’s focus on the parent– child relationship taps important aspects of young children’s functioning
that are not captured in the DSM-IV. In
addition, the DC: 0 –3 emphasizes regulatory disorders more than the DSM-IV
does. However, the DC: 0 –3 system has
not been studied using the procedures for
assessing reliability and validity that are
standard in the field. These standard procedures include using a large sample that
includes “cases” with diverse problems as
well as “noncases” measuring agreement
between independent raters, and validating the diagnoses with data that were not
used in the diagnostic process.
Temperament Scales
Another widely used approach to
the assessment of young children involves
the rating of temperamental characteristics. Commonly used approaches for assessing temperament include parent ratings, home observation, and lab-based
assessment [Stifter and Wiggins, 2004].
Because they are the simplest and most
efficient, parent report scales are the most
widely used means for measuring temperament. The Revised Infant Temperament Questionnaire [Carey and McDevitt, 1978], the Buss and Plomin [1984]
EAS Temperament Survey, and the
Rothbart [1981] Infant Behavior Questionnaire are among the parent rating
scales commonly used for assessing temperament. Such scales vary in length,
scoring (continuum or dichotomous
scoring), and dimensions tapped.
Studies of parent temperament ratings have often demonstrated associations
between characteristics of the rater and
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child temperament scores [Stifter and
Wiggins, 2004]. For example, mothers
who are depressed, anxious, overly
stressed, or of low socioeconomic status
(SES) typically report more difficult temperament in their young children. Similarly, mothers’ prenatal “working model”
of the infant and their ratings of aversiveness or tape-recorded crying predict their
subsequent ratings of temperament.
These findings indicate that it is important to obtain temperament ratings from
additional informants to determine the
degree to which temperamental characteristics reported by the mother are
unique to her perspective or are corroborated by others. In studies examining
this question; such as the report by Seifer
et al., [1994], agreement between maternal ratings and trained observers has been
low.
Researchers have used a variety of
observational methods for assessing temperament, such as those by Garcia Coll et
al., [1992] and by Goldsmith and Rothbart [1991]. However, such procedures
require extensive training, and they provide a restricted range of observational
contexts. Additionally, observational
measures must be collected over numerous sampling occasions to be reliable [Seifer et al., 1994; Sifter and Wiggins,
2004], precluding their use in clinical
settings.
GOALS/OBJECTIVES OF THE
ASEBA PRESCHOOL FORMS
The ASEBA preschool instruments
were designed to be user-friendly, standardized tools that can be utilized by
different kinds of professionals assessing
children in diverse settings. An important
feature of ASEBA instruments is that
they do not require professional time or
training for either administration or scoring.
Young children are evaluated in
different centers, including pediatric primary care centers, early intervention services, child development clinics, tertiary
medical centers, community mental
health centers, private practices, child
care settings, child welfare/protective
service agencies, foster care services, and
research settings. Reasons for assessment
may include planning therapeutic and
educational interventions, mounting prevention efforts, deciding on placements,
determining custody, and studying etiologies, correlates, interventions, and outcomes of problems. Assessment must be
able to take account of possible variations
related to ethnicity, family constellation,
SES, and languages spoken in the home.
The assessment methods need to be us228
able by many kinds of professionals, such
as nurses, educators, child development
specialists, pediatricians, child and family
service workers, social workers, psychiatrists, and psychologists.
Although direct observation of the
child and caregivers is always important,
young children’s behavior is often highly
variable. For example, time of day, physical state, environmental context, interaction partner, and presence of observers
may all affect a child’s behavior. Even an
in-depth clinical assessment over multiple settings and days can sample only a
small fraction of the child’s possible behaviors. Furthermore, young children
cannot be expected to report on their
own functioning. Thus, it is essential to
obtain reports of the child’s behavioral
and emotional characteristics by adults
who know the child well, such as parents, caregivers, and teachers. Because
young children may manifest many different kinds of problems, assessment instruments need to be comprehensive
enough to detect possible problems of
many types.
Based on these considerations, the
CBCL/1.5–5 and the C–TRF were designed to provide normed scores on a
wide array of behavioral and emotional
problem scales in young children. Because language is so important for young
children’s adaptive development, an additional goal in developing the CBCL/
1.5–5 was to obtain a quick screen of
language development for children from
1.5 to 3 years of age. Thus, the CBCL/
1.5–5 includes the Language Development Survey (LDS) [Rescorla, 1989]. Inclusion of the LDS with the CBCL/
1.5–5 makes it easy to simultaneously
determine whether children who appear
to have language delays are also reported
to have more behavioral/emotional
problems than normative samples of
peers. Conversely, when assessing behavioral/emotional problems, practitioners
can simultaneously screen for language
delay.
HISTORICAL BACKGROUND
OF THE ASEBA PRESCHOOL
INSTRUMENTS
The empirically based paradigm
was first applied to young children when
the CBCL for ages 2–3 was constructed
in 1981 for assessment of low birth
weight children [Achenbach et al., 1987].
This was followed by the C–TRF for
ages 2–5 [Achenbach, 1997]. In 2000,
revisions of these instruments were published [Achenbach and Rescorla, 2000].
Two items from the CBCL/2–3 [Achenbach, 1992] were replaced by new items
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for the CBCL/1.5–5. No items were
changed from the C–TRF/2–5 [Achenbach, 1997].
The CBCL 1.5–5 and the C–TRF
[Achenbach and Rescorla, 2000] improved on the previous versions in the
following ways: (a) the age range of both
the CBCL and the C–TRF were extended so that both forms now span ages
1.5–5, (b) the LDS [Rescorla, 1989], a
parent-report screening tool for language
delay, was added to the CBCL/1.5–5, (c)
new empirically based scales were developed for the CBCL/1.5–5 and C–TRF,
(d) new DSM-oriented scales were constructed for both instruments, and (e)
new computerized scoring programs
were developed to provide cross-informant comparisons for up to eight forms
per child.
Data for norming the ASEBA preschool forms were collected as part of the
1999 National Survey of Children,
Youth, and Adults, which involved over
10,000 participants ages 1.5–90⫹. Temple University’s Institute for Survey Research conducted the National Survey
using its national sampling frame of 100
Primary Sampling Units (PSUs), chosen
to be collective representative of the 48
contiguous states. Interviewers within
each PSU were assigned listing areas of
⬃150 households. They visited each
household in their listing areas to determine age and gender of residents; 99% of
households visited provided such information. After eligible preschool children
were identified (age between 18 and 71
months, with at least one parent who
spoke English), candidate children were
selected by stratified random sampling.
Of the 781 eligible preschool children
recruited, the CBCL was completed for
738 (94.4% completion rate). Children
who had received mental health or special education services in the past year
were excluded from the normative sample (38 children, 5.1%), yielding a final
sample of 700 children who were
“healthy” in epidemiological terms.
This CBCL/1.5–5 normative sample consisted of 362 boys and 338 girls.
The sample was representative of the ethnic diversity of the United States, with
56% NonLatino white, 21% African–American, 135 Latino, and 10% mixed or
other (South Asian, Asian, and Native
American). Non-English languages were
spoken in about 25% of the homes. The
other language was typically Spanish, but
Tagalog, Chinese, Vietnamese, Tamil,
American Sign Language, Bengali, Japanese, and Farsi were also spoken. The
SES of the sample was 33% upper, 49%,
middle, and 17% lower, based on an up-
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dated version of Hollingshead’s [1975]
9-step scale for coding parental occupation. Regional distribution was 17%
Northeast, 22% Midwest, 40% South,
and 21% West.
The C–TRF normative sample
contained 203 children whose parents
completed the CBCL/1.5–5 who attended daycare or preschool, whose parents gave consent to contact a caregiver
or teacher, and whose caregiver or
teacher completed and returned the
form. To augment this sample, 989 children from the 1997 C–TRF/2–5 normative sample [Achenbach, 1997] were
added. The 1997 C–TRF normative
sample consisted of 753 children recruited in the National Institute of Child
Health and Development Study of Early
Child Care [NICHD Early Child Care
Research Network, 1994] recruited in 9
states, plus 36 children drawn from 14
daycare and preschool programs in 12
states. The final 2000 C–TRF normative
sample thus consisted of 1,192 children,
588 boys and 604 girls. Ethnicity was
48% NonLatino white, 36% African–
American, 8% Latino, and 9% mixed or
other. SES distribution was 47% upper,
43% middle, and 10% lower. Regional
distribution was 29% Northeast, 17%
Midwest, 32% South, and 22% West.
DESCRIPTION OF
ADMINISTRATION
PROCEDURES
The CBCL/1.5–5 is completed by
parents, parent surrogates, and others
who see children in home-like contexts.
The C–TRF is completed by daycare
providers and preschool teachers. The
CBCL/1.5–5 and the C–TRF have 82
similar problem items, plus 17 items that
are specific to home versus daycare and
preschool contexts, and an open-ended
item for adding other problems that are
not listed on the forms. Both forms request respondents to rate each item as
follows: 0, not true; 1, somewhat or
sometimes true; or 2, very true or often
true of the child now or within the past 2
months [Achenbach and Rescorla,
2000]. Both forms also request descriptions of behavior, illnesses, disabilities,
what concerns the respondent most
about the child, and the best things about
the child. Thus, the forms not only provide quantitative scores for each problem
item, but they also yield descriptions of
the child’s functioning in the respondent’s own words. The LDS portion of
the CBCL/1.5–5 requests respondents to
provide information about possible risk
factors for language delays, to report five
of the child’s best word combinations if
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the child is combining words, and to
circle on a 310-word vocabulary list the
words used by the child.
Completion of the ASEBA forms
requires only 5th grade reading skill. If
there are questions about a respondent’s
ability to complete a form independently,
the following procedure is recommended: An interviewer hands the respondent
the form while retaining a second copy.
The interviewer then says, “I’ll read you
the questions on this form and I’ll write
down your answers.” Respondents with
adequate reading skills will often start answering without waiting for the questions to be read. However, for respondents who cannot read well, this
procedure avoids embarrassment while
maintaining the standardization of the assessment process.
ADMINISTRATION TIME
The ASEBA preschool forms can
be completed independently by most respondents in about 10 min. Completion
of the LDS also takes about 10 min, and
for a total CBCL/1.5–5 completion time
of 20 min.
TRAINING REQUIRED
No professional training is required
for administration of the ASEBA preschool forms. Instructions on the forms
make them self-explanatory. In many
settings, the CBCL/1.5–5 is sent to parents by mail along with various other
forms, such as consent forms and developmental history forms. The C–TRF is
also routinely sent to teachers and daycare providers, after parents have provided consent. Parents, teachers, and
daycare providers can then mail back the
forms, which can be scored by a clerical
worker or by a professional, using the
ASEBA computer scoring program.
Computer-scoring takes about 5 min per
form. It is also possible to hand-score the
forms, using a set of scoring templates
and profiles. However, hand-scoring
takes more time than computer scoring
(10 –15 min per form) and does not yield
the same cross-informant displays that
computer scoring generates. ASEBA also
offers a web-based utility called WebLink, whereby forms can be sent, completed, returned, and scored via the Internet.
Although administering and scoring the ASEBA forms require no professional training, interpretation of the information obtained does require
professional training related to children’s
behavioral and emotional problems. Interpretation of the LDS also requires
some familiarity with the process of lanOF
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guage acquisition in young children.
Graduate training at the master’s level or
the equivalent is the appropriate user
qualification for ASEBA forms.
DESCRIPTION OF SCORING
SYSTEM
LDS Scores
The LDS portion of the CBCL/
1.5–5 is scored by adding up the number
of words circled and by calculating the
number of words in each phrase/sentence provided. Simple scoring rules are
provided for determining the number of
words in multiword utterances (e.g.,
“thank you” is counted as a single word
utterance). Number of vocabulary words
is scored in relation to national norms for
children at ages 18 –23 months, 24 –29
months, and 30 –35 months. The average
length of word combinations is only
scored for the ages 24 –29 and 30 –35
months, because before 24 months children often do not combine words
[Achenbach and Rescorla, 2000].
Figure 1 displays the scores obtained from the LDS completed for 30month-old Kenny Randall by his
mother. Based on the ratings from Kenny’s mother, both his vocabulary score
(55th percentile) and his average length
of phrases score (50th percentile) were
above the cutpoints for concern (15th
and 20th percentiles, respectively). Although Ms. Randall wrote five sentences
for Kenny, she added that the sentence
“Doesn’t open, Ben” was one for the
only times she had ever heard Kenny
speak in a meaningful, communicative
way with another child. The paucity of
communicative sentences raised questions about Kenny’s pragmatic language
skills.
CBCL/1.5–5 and C–TRF
Empirically Based Scores
Both the CBCL/1.5–5 and the
C–TRF yield scores on empirically based
syndromes. These syndromes were derived by conducting exploratory and
confirmatory factor analyses of item
scores for large samples of children. Factor analysis of problems works best if the
forms utilized have non-zero scores on a
substantial number of items. Thus, the
CBCL/1.5–5 and C–TRF factor analytic
samples included all children from the
1999 National Survey sample scoring
above the median for Total Problems,
plus many other children from clinical
and nonclinical settings whose Total
Problems scores were at or above the
National Survey median (for factor analyses of the CBCL/1.5–5 total N ⫽
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Fig. 1.
Kenny Randall’s LDS scoring profile.
1,728; for the C–TRF, N ⫽ 1,113).
Analyses conducted for each gender separately on each instrument identified the
following six syndromes for both genders
scored on both instruments: Aggressive
Behavior, Anxious/Depressed, Attention
Problems, Emotionally Reactive, Somatic Complaints, and Withdrawn. In
addition, analyses of the CBCL/1.5–5
identified a syndrome designated as Sleep
Problems, which consists of sleep-related
items that are not assessed by the
C–TRF.
A child’s score on a syndrome is
obtained by summing the ratings for the
items that comprise the syndrome. Scores
for each item of each syndrome and the
total score for each syndrome are displayed on a profile, as shown for 30month-old Kenny in Figure 2. The profile displays Kenny’s scores in relation to
scores for the 700 children from the
CBCL/1.5–5 normative sample. For
each syndrome scale, the broken lines
printed across the profile indicate a nor230
mal range (⬍93rd percentile), a borderline clinical range (93rd to 97th percentile), and a clinical range (⬎97th
percentile). Figure 2 indicates that Kenny’s mother’s ratings yielded scores in the
clinical range (above the top broken line)
on the Withdrawn syndrome and in the
borderline clinical range (between the
broken lines) on the Emotionally Reactive syndrome.
CBCL/1.5–5 and C–TRF Aggregate
Scales
The ASEBA preschool forms also
yield three aggregate (broad-band)
scores. When the preschool syndromes
were submitted to a “second order-factor
analysis,” two global groupings emerged,
which are labeled “Externalizing” and
“Internalizing.” Similar scales have been
found in multivariate analyses of children’s behavioral/emotional problems
for many different instruments over several decades of research [Achenbach and
Rescorla, 2000]. For the preschool
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forms, the Emotionally Reactive, Anxious/Depressed, Somatic Complaints,
and Withdrawn syndromes loaded on the
Internalizing scale, whereas the Aggressive Behavior and Attention Problems
syndromes loaded on the Externalizing
scales Finally, all the items on the CBCL/
1.5–5 and the C–TRF are summed to
yield a Total Problems score for each
form.
For Internalizing, Externalizing,
and Total Problems, the clinical range
is defined as T scores ⱖ64 (about the
90th percentile), the borderline range
consists of T scores from 60 to 63 (84th
to 90th percentiles), and the normal
range consists of scores below the 84th
percentile (T ⬍ 60). The reason for
selecting lower clinical and borderline
range cutpoints than those on the syndromes is that the Internalizing, Externalizing, and Total Problems scales encompass more numerous and more
diverse problems than any single syndrome scale.
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Fig. 2.
Kenny Randall’s CBCL syndrome profile.
DSM-Oriented Scales
Because practitioners and researchers are often expected to evaluate children’s problems in terms of diagnostic
categories, there is a need to link empirically based assessment with such categories. The empirically based paradigm
takes a “bottom-up” approach whereby
syndromes are derived statistically to reflect patterns of problems that are found
to co-occur in large samples of individuals rated by various kinds of informants.
The DSM, by contrast, takes a “topdown” approach whereby experts formulate diagnostic categories and then select symptoms and other criteria for
defining each category. Although numerous studies have shown statistically
significant associations between DSM diagnoses and empirically based syndromes,
the obtained associations vary greatly according to the basis for making DSM
diagnoses, the sources of data, the particular diagnostic categories, and the analytic methods (e.g., Edelbrock and
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Costello, 1988; Rey and Morris-Yates;
1992; Gould et al., 1993; Arend et al.,
1996; Kasius et al., 1997].
To help practitioners and researchers view the problem items of the
CBCL/1.5–5 and C–TRF in relation to
DSM diagnostic categories as well as empirically based syndromes, we constructed DSM-oriented scales [Achenbach et al., 2000]. Sixteen experienced
child psychiatrists and psychologists from
10 cultures were invited to rate each of
the CBCL/1.5–5 and C–TRF problem
items as not consistent, somewhat consistent, or very consistent with each of
nine DSM diagnostic categories. Items
that were rated as very consistent with a
DSM category by at least 10 of the 16
raters (63%) were deemed to be sufficiently consistent with DSM categories
to be included in the DSM-oriented
scales.
Because of major overlaps in DSM
diagnostic criteria, as well as in the obtained ratings of the problem items, the
OF
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nine DSM categories were collapsed into
the following five scales: Affective Problems (including Major Depressive Disorder and Dysthymic Disorder), Anxiety
Problems (including Generalized Anxiety Disorder, Separation Anxiety Disorder, and Specific Phobia), Attention Deficit/Hyperactivity Problems (including
Hyperactive–Impulsive and Inattentive
types), Pervasive Developmental Problems (including Asperger’s Disorder and
CBCL/1.5–5 versus C–TRF). There are
some differences between the items of
the CBCL/1.5–5 and C–TRF versions
of the DSM-oriented scales. For example, the C–TRF version of the Attention
Deficit/Hyperactivity Problems scale has
more items than the CBCL/1.5–5 version, because more attention problem
items are appropriate for rating by daycare providers and teachers than by parents and parent surrogates.
The profiles of DSM-oriented
scales are analogous to the profiles of
empirically based syndromes, as illus-
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Fig. 3.
Kenny Randall’s CBCL DSM-oriented profile.
trated by the profile of DSM-oriented
scales shown for Kenny in Figure 3. Like
the scales for the empirically based syndromes, the score for each DSM-oriented scale is computed by summing the
0 –1–2 ratings of the items that comprise
the scale. The profiles of DSM-oriented
scales display children’s scores in relation
to the same national normative samples as
for the empirically based scales, with percentiles, T scores, and normal, borderline, and clinical ranges displayed in the
same way as for the empirically based
scales.
As can be seen in Figure 3, Kenny’s
DSM-oriented profile for the CBCL,
completed by his mother, yielded scores
in the clinical range for both the Affective Problems and the Pervasive Developmental Problems scales. It should be
noted that a high score on a DSM-oriented scale is not directly equivalent to a
DSM diagnosis for the following reasons:
(a) the items of the DSM-oriented scales
232
do not correspond precisely to DSM criteria, (b) the DSM-oriented scales are
quantitative, whereas the DSM is based
on yes-or-no judgments, and (c) DSM
criteria are the same regardless of the
informant who provides the data,
whereas the DSM-oriented scales are
normed based on the type of informant.
However, the DSM-oriented scales are
useful in suggesting diagnoses that may
be relevant to consider for a particular
child.
INTER-RATER RELIABILITY:
THE IMPORTANCE OF CROSSINFORMANT COMPARISONS
Children often behave differently
in different settings and with different
interaction partners. Furthermore, two
people seeing the same behavior may report it differently. Meta-analyses of correlations between scores obtained from
informants’ reports of problems for 1.5–
19-year-olds found an average correla-
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tion of 0.60 between pairs of informants
who play similar roles with respect to
children, such as pairs of parents and pairs
of teachers [Achenbach et al., 1987]. Between informants who play different
roles with respect to children, such as
parents versus teachers and teachers versus mental health workers, the correlations averaged 0.28.
In the 1999 National Survey, a
mean correlation of 0.61 was found
when z-transformed correlations between scores obtained from 72 pairs of
mothers and fathers on all CBCL syndromes, DSM-oriented scales, and aggregate scores were averaged. When
z-transformed correlations between
scores provided by 102 pairs of caregivers/teachers across all C–TRF scales
were averaged, the mean correlation was
0.65. When z-transformed correlations
between scores obtained on all CBCL/
C–TRF scales from 226 parent– caregiver/
teacher pairs were averaged, the mean
YOUNG CHILDREN USING ASEBA
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Fig. 4.
Kenny Randall’s cross-informant bar graph.
correlation was 0.40. For Total Problems
scores, the mean cross-informant correlations were 0.65 for pairs of parents on
the CBCL, 0.72 for pairs of teachers on
the C–TRF, and 0.50 for parents with
teachers on the CBCL and C–TRF, respectively [Achenbach and Rescorla,
2000].
Even though reports by each kind
of informant may be reliable and valid in
their own right, the modest agreement
among informants indicates that no single
informant can substitute for all others.
Because children’s behavior varies from
one context and interaction partner to
another and because informants differ in
what they notice, remember, and report,
comprehensive assessment requires data
from multiple informants. Therefore, the
ASEBA preschool forms and profiles
provide several ways to systematically
compare data from multiple informants.
One way information from multiple informants is compared is by the crossinformant bar graph. Figure 4 illustrates a
cross-informant bar graph of Kenny
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Randall for CBCLs completed by his
mother and father and C–TRFs completed by his two teachers.
As can be seen in Figure 4, ratings
by all four adults yielded scores in the
clinical range for the Withdrawn syndrome and in the borderline range for the
Emotionally Reactive syndrome. On the
other hand, only teachers’ ratings placed
Kenny in the clinical range for the Attention Problems syndrome and the borderline range for the Somatic Complaints
syndrome. Kenny’s cross-informant bar
graph for the DSM-oriented scales (not
shown here) indicated that ratings by all
four adults placed him in the clinical
range on the Pervasive Developmental
Problems scale, whereas only his teachers
yielded elevated scores on the Anxiety
Problems and Attention Deficit Hyperactivity Problems scales.
Another way that the ASEBA software facilitates cross-informant comparisons is by printing correlations between
ratings by each pair of informants and
comparing these correlations with correOF
YOUNG CHILDREN USING ASEBA
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lations obtained for large reference samples of similar pairs of informants. This
enables users to evaluate how well particular informants agree with one another
in rating a particular child. The software
also prints side-by-side comparisons of
the scores obtained from each informant
on each item and each scale, enabling
users to see at a glance the items and
scales on which there are consistencies
versus inconsistencies among the informants.
PSYCHOMETRIC PROPERTIES
OF THE ASEBA PRESCHOOL
FORMS
Reliability
To assess test–retest reliability of
the CBCL/1.5–5, maternal ratings for 68
nonreferred children obtained about one
week apart were compared using both
correlations and t-tests. Similar analyses
were done on C–TRF ratings for 59
children. Across the various ASEBA syndromes and scales, most test–retest cor-
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233
relations were in the 0.80s and 0.90s,
with a mean r of 0.85 and 0.81 across all
scores for the CBCL and C–TRF, respectively. The Total Problems r was
0.90 for the CBCL and 0.88 for the
C–TRF. Test–retest reliability for the
LDS was 0.99 in a sample of 30 toddlers
assessed over a one-week interval and
0.97 for 33 toddlers assessed over a onemonth interval [Achenbach and Rescorla, 2000].
When t-tests were used to compare
CBCL and C–TRF problem scores
across the first and second administrations, there was a small decline in scores
(about 1% of the variance on both
forms). A decline in scores when an assessment procedure is repeated after a
short interval is called test–retest attenuation. The test–retest attenuation effects
found for ASEBA forms are smaller than
those typically obtained on structured diagnostic interviews [Edelbrock et al.,
1985].
Validity
Validity of the ASEBA preschool
forms has been examined in several ways.
In one set of analyses, ASEBA scores
were compared for referred versus nonreferred children (N ⫽ 563 for each)
matched on age, gender, SES, and ethnicity. In regression analyses, the effect
size (ES) for referral status ranged from
3% (DSM-oriented Anxiety Problems) to
25% (Total Problems) of the variance for
CBCL scales and from 2% (Somatic
Complaints) to 24% (Total Problems) of
the variance for C–TRF scales. Referred
children obtained significantly higher
scores on all problem scales of the
CBCL/1.5–5 and C–TRF, with 16 of
the 29 effects meeting Cohen’s [1988]
standards for “medium” size (⬎13% of
the variance). Referred children also obtained higher scores on all but two items
of the CBCL/1.5–5 and C–TRF.
Age effects on CBCL/1.5–5 scores
were generally very small, and this is the
reason that the same norms for the
ASEBA preschool forms span the entire
age 1.5–5. Gender effects were few and
very small on the CBCL, and so genders
were pooled for the norms. Because 8 of
the 14 gender effects on the C–TRF
were significant, albeit small (2–3% of the
variance), separate C–TRF norms for
boys and girls were developed. There
were no significant SES effects on the
C–TRF, but small SES effects (1–3% of
the variance) were found for 8 of the 15
CBCL scales.
For the LDS, significant gender effects for vocabulary score necessitated
separate norms by gender. However, the
234
gender difference for average length of
combinations was not significant, so genders were pooled for this measure. Age
differences were significant for both LDS
measures, which is why norms are provided for the three age groups for vocabulary score and for the two older age
groups for average length of combinations.
The relations between referral status and scores in the deviant range (above
the borderline cutpoint) on each CBCL
scale were analyzed using odds ratios
(ORs) for the same demographicallymatched samples described above
[Achenbach and Rescorla, 2000]. The
OR indicates the odds of the child being
in the referred versus the nonreferred
group given a score in the deviant range
on an ASEBA scale. The highest OR was
for the DSM-oriented Pervasive Developmental Problems scale (OR ⫽ 11);
children with a Pervasive Developmental
Problems T score ⬎65 were 11 times
more likely to be in the referred group.
When the predictor was having at least
one CBCL syndrome in the deviant
range, the OR was 9; 77% of referred
children but only 26% of nonreferred
children had at least one CBCL syndrome with T score ⬎65. Similarly, 57%
of the referred group and 18% of the
nonreferred group had a Total Problems
score in the deviant range (T ⬎ 60) on
the CBCL (OR ⫽ 6); the corresponding
figures for the C–TRF were 63% versus
18% and an OR ⫽ 8.
Criterion-related validity has also
been demonstrated for the LDS [Achenbach and Rescorla, 2000]. Correlations
between LDS vocabulary score and other
language measures across 11 samples
ranged from 0.56 to 0.87, with 11 of the
15 correlations ⬎70. The language measures used in these 11 samples included
number of different objects named on
Bayley [Bayley, 1969], number of different pictures named on the Stanford–
Binet IV [Thorndike et al., 1986], number of pictures named on the Reynell
Expressive Language Scale [Reynell and
Gruber, 1985], total scores on the Reynell Expressive and Receptive Language
Scales, language score on the Mullen
Scales [Mullen, 1993], mean length of
utterance from a speech sample, parent
report on a Spanish version of the
MacArthur CDI [Fenson et al., 1993],
and Communication scores on the Vineland Adaptive Behavior Scale [Sparrow
et al., 1984]. Sensitivity of the LDS for
identifying children found to be language-delayed on formal testing was 87%
in one study [Rescorla, 1989], 91% in
another study [Klee et al., 1998], and
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94% in a third study [Rescorla and Alley,
2000], based on the scores of either the
Reynell Expressive Language Scale [Rescorla, 1989; Rescorla and Alley, 2000] or
the Mullen Scales [Klee et al., 1998].
Specificity, or the percent of typically
developing children who passed the
LDS, was 86, 87, and 67% across the
same three studies. In the Rescorla and
Alley [2001] study, an OR of 34 was
found: Children who “failed the LDS”
by having fewer than 50 words or no
word combinations at 24 months were
34 times more likely to obtain a score
ⱕ10th percentile on the Reynell Expressive Language Scale than toddlers who
“passed the LDS.”
UTILIZING ASEBA FORMS IN
SERVICE SETTINGS
The CBCL/1.5–5 and C–TRF are
appropriate for use in diverse service settings. The standardized rating forms can
be completed by people such as parents,
parent-surrogates, daycare providers, and
preschool teachers when children are
evaluated in various contexts. In many
settings, practitioners can have parents
routinely complete the CBCL/1.5–5 at
home prior to their scheduled appointment. Once parental consent is obtained,
C–TRFs can also be obtained from
teachers and daycare providers. By looking at the child’s computer-scored or
hand-scored profiles and the LDS scoring
form, the practitioner can quickly see
whether the child is in the normal range
with respect to problem scores and language development. If the child is not in
the normal range, the practitioner can
use the profile and the descriptive comments written on the CBCL/1.5–5 as a
basis for interviewing the parent about
the child’s functioning. If syndrome
scores are very elevated or if there is
evidence for deviance in multiple areas,
the practitioner may elect to conduct a
more extensive evaluation or to refer the
family to a specialist. If referral to a specialist is indicated, the completed CBCL/
1.5–5, LDS, and profile forms can be
sent, with parents’ consent, to the specialist to provide intake information.
The ASEBA preschool forms are a
useful component of the intake and evaluation process in special education, child
development, and mental health settings.
Whether referrals arise from concerns
about language development, cognitive
functioning, stressful experiences such as
abuse or neglect, or behavior problems, it
is always helpful to have a standardized
picture of the child’s behavioral/emotional problems and language development, as seen by people who live with
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the child. Such a picture is also essential
for evaluations related to adoption and
foster placement.
USING ASEBA FORMS IN
RESEARCH
ASEBA preschool forms have been
widely used in research. One such use is
to evaluate effects of interventions. The
CBCL/1.5–5, LDS, and C–TRF can be
administered before, during, and after interventions to evaluate changes and outcomes, as exemplified in studies of interventions for low birth weight children
from low SES families [Brooks-Gunn et
al., 1994] and for children at-risk because
of psychosocial adversities [Kitzman et
al., 1997]. Many studies have demonstrated the sensitivity of ASEBA preschool scales to the effects of interventions. For example, Blair [2002] reported
findings from the Infant Health and Development Program for low birth weight
children, which involved both home visiting and child– care components. Twothird of the mothers had a high-school
education or less, and 63% of the sample
was African–American or Hispanic. Results indicated that infants rated by their
mothers as high in negative emotionality
showed significant intervention effects by
age 3, with half as many intervention
children scoring in the deviant range
(T ⱖ 64) on CBCL/2–3 Internalizing or
on Externalizing problems as control
group children. When an elevated score
on both Internalizing and Externalizing
was used as the outcome measure, control group children who had showed
negative emotionality as infants were
four times more likely to be deviant at
age 3 than intervention children.
ASEBA forms can be combined
with other assessment instruments in
large research studies investigating multiple aspects of development. For example,
the NICHD Study of Early Child Care
used the ASEBA preschool forms in its
longitudinal investigation of more than
1,000 children in 10 sites ([NICHD Early
Child Care Research Network, 1998]. In
a study reported by Belsky and Fearon
[2002] from this project, age 3 scores on
the CBCL/2–3 showed a significant linear dose-response relation with level of
“cumulative risk,” a composite based on
measures of SES, race, maternal education and psychopathology, parenting
stress, social support, marital status, and
marital quality. In another report from
this larger study, La Paro et al. [2002]
examined developmental predictors of
eligibility for special services as determined by a medical professional. Results
indicated that high CBCL/2–3 scores
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and problematic health history from 16
to 36 months were the only significant
predictors of special needs identification
out of 9 candidate predictors tested, with
the full model correctly predicting status
of 73% of the children.
Scores on ASEBA forms have also
been used in studies designed to analyze
the mechanisms by which a general risk
factor such as low SES produces negative
outcomes for children. For example, Linver et al. [2002] found that the effect of
low SES on CBCL behavioral/emotional
problems was mediated by two major
factors, low cognitive stimulation and
poor parenting practices. Poor parenting
practices, but not low cognitive stimulation, were in turn mediated by povertyrelated maternal emotional distress.
Longitudinal studies from preschool to school-age can also be done
with ASEBA forms. As an example of
longitudinal analyses of this sort, the preschool CBCL was used in a study of
children who had participated in an experimental short-term intervention designed to facilitate the development of
low birth weight infants [Achenbach et
al. 1993]. Children were assessed at ages 2
and 3 by having the parents complete the
preschool CBCL and at older ages by
having them complete the CBCL/6 –18.
The longitudinal correlations between
scores for the Aggressive Behavior syndrome at age 2 and later ages were substantial, ranging from 0.65 between ages
2 and 4 to 0.50 between ages 2 and 9
[Achenbach and Rescorla, 2000].
The ASEBA preschool forms have
also been used for research in other cultures. For example, a Dutch translation of
the CBCL/2–3 was used with 420 children in a community sample, 426 clinic
referred children, and 1,306 twin pairs
[Koot et al., 1997]. Factor analysis of
item scores yielded the same six factors
across the three samples: Oppositional,
Withdrawn/Depressed, Aggressive, Anxious, Overactive, and Sleep Problems.
These are quite similar though not identical
to the American syndromes, despite the
fact that different factor analytic methods
were used. A second-order factor analysis
yielded Externalizing (Aggressive, Oppositional, and Overactive syndromes) and Internalizing (Anxious, Withdrawn/Depressed) aggregate scales, similar to those
found in the USA. Test–retest reliabilities
were high (0.87 for Total Problems), and
mother–father inter-rater reliability was
0.66, both comparable with data from the
USA. When demographically-matched referred and nonreferred children were compared, all problem scales were significantly
higher in the referred children (ES of 27%
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for Total Problems). As in the USA, age,
gender, and SES effects were significant but
quite small. A deviant score on the Total
Problems scale (⬎85th percentile) yielded
an OR of 8.7 for clinic versus nonreferred
status, with 73% of the children being correctly classified. Correlations of CBCL/
2–3 scores with comparable scores from the
Dutch CBCL/4 –16 two years later were
0.41, 0.54, and 0.60 for Internalizing, Externalizing, and Total Problems scores, respectively, which are quite similar to
American findings. Finally, when scores
based on the Dutch scales were compared
with those obtained for the same children
using the American scales, correlations
were 0.90 for Internalizing and 0.97 for
Externalizing, and they ranged from 0.80
to 1.00 for individual syndromes.
The psychometric properties of an
Arabic translation of the CBCL/2–3
have been examined in a sample of 694
three-years-old children in the United
Arab Emirates (Yunis F, Eapen V, and
Zoubeidi, T (personal communication)
The CBCL and several other measures
were administered by an interviewer in
the home. Items with a reported prevalence of less than 5% were excluded from
further analyses, leaving 71 problem
items on six empirically based syndromes.
Internal consistency indexed by Cronbach’s alpha was very high for the Total
Problems score (0.93), and quite high for
Internalizing (0.76) and Externalizing
(0.88); alpha values for syndromes ranged
from 0.55 for Withdrawal to 0.84 for
Aggressive Behavior. Test–retest reliability over a one week interval was 0.82 for
Total Problems, and ranged from 0.60 to
0.75 for the six syndromes. Children
with a family history of psychiatric illness
or psychosocial stress had significantly
higher CBCL scores. When children
scoring two standard deviations above
the mean on Total Problems (“high scorers”) and a contrasting “low scoring”
group were interviewed by a clinician
unaware of their CBCL scores, 94% of
“high scorers” and 0% of low scorers
were judged to have a “clinically significant problem.” Thus, the CBCL/2–3
demonstrated excellent external validity,
despite the many cultural differences between the USA and the United Arab
Emirates.
CAUTIONS AND LIMITATIONS
ASEBA preschool forms are designed to improve clinical assessment and
services by providing standardized rating
forms usable by multiple informants who
see the child in different contexts.
ASEBA forms are intended to be integrated with rather than to substitute for
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235
cognitive assessment, physical examinations, psychiatric diagnosis, observations,
and developmental histories. Each of
these is essential for comprehensive assessment and understanding of young
children. Detailed knowledge of family
functioning and relationships is also
needed to understand both the liabilities
and strengths that characterize families.
Evaluation of cognitive, physical, and
family functioning requires considerable
time and effort by skilled clinicians. At
low cost, empirically based assessment
adds much useful data without requiring
clinicians’ time. However, clinicians
must ultimately integrate empirically
based assessment data with other data. A
major challenge is to help clinicians
weigh and integrate various kinds of data
to make the best decisions for each child.
STRENGTHS AND BENEFITS
OF THE ASEBA APPROACH
The ASEBA preschool forms are
standardized assessment instruments that
are user-friendly, cost-effective, and usable by a wide range of professionals in
different settings. The CBCL/1.5–5 and
C–TRF yield scores on normed empirically based syndrome scales, DSM-oriented scales, and Internalizing, Externalizing and Total Problems aggregate
scales. The norms are based on large and
diverse general population samples. Findings based on ASEBA forms for preschool children have been reported in
more than 200 published research studies. The CBCL/1.5–5 also contains the
LDS, which can be used for reliable and
valid screening of language delay in children from 18 months to 3 years of age.
Because there is no single gold
standard for assessing behavioral and
emotional problems, the empirically
based approach employs parallel assessment forms to obtain data from multiple
informants who see children in different
contexts and from different perspectives.
ASEBA software systematically compares
item and scale scores obtained from up to
eight informants per child. The software
also computes correlations between ratings by different informants and compares these correlations with those obtained for large reference samples of
informants.
Because ASEBA DSM-oriented
scales are scored from the same rating
forms and are normed on the same national samples as the empirically based
syndromes, users can directly compare
reports of children’s problems grouped
according to DSM categories and
grouped according to empirically based
syndromes. Categorical cutpoints on all
236
the scales enable users to categorize children as being in the normal, borderline,
or clinical range.
Clinical applications of empirically
based instruments include routine use in
health care settings to identify children
with deviant problem scores and to advise parents, daycare providers, and
teachers who are concerned about a
child’s problems. Other clinical applications include use of the empirically based
instruments to evaluate children seen in
special education, child development,
and mental health settings; to evaluate
changes during interventions, as well as
outcomes following interventions; and to
evaluate children involved in adoption
and foster placement.
Research applications for ASEBA
preschool forms include identifying correlates of different kinds of problems,
tracking the developmental course of
problems, testing the efficacy of pharmacotherapy and other interventions, identifying etiological factors, and evaluating
prevention programs. Because the
CBCL/1.5–5 and C–TRF have counterpart forms for assessing school-age children and adolescents, it is easy to test
predictive relations between scores obtained on the forms for ages 1.5–5 and
the forms for ages up to 18. f
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