An Overview of the Use of the

Child Behavior Checklist

within Australia An Overview of

An Overview of the Use of the Child Behavior Checklist within

the Use of the
Australia provides a comprehensive review of selected Australian
studies conducted over the past 20 years that have used the Child Behavior Checklist
Child Behavior Checklist. The strengths and weaknesses of the
CBCL for use in the Australian population are highlighted.
within Australia
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 Aus-

tralian samples.

Cross-informant stability between parents, children and
Heather Siddons and
teachers of behavioral and emotional problems.

The relationship between a range of psychosocial factors and
Sandra Lancaster
CBCL ratings.

ISBN 0-86431-627-5

9 780864 316271
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

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 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

1.2.1 Social Competence Scales 1
1.2.2 Problems at Various Levels 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) 6

3.1.1 Morbidity Rates 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 9

3.3.1 Sample Description 9
3.3.2 Problem Behaviors 9
3.3.3 Cutoff Scores 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 11

3.5.1 Sample Description 11
3.5.2 Level of problems 11
3.5.3 Comparisons between Sydney and American Data 12

3.6 Conclusions 12

4 MORBIDITY STUDIES IN SELECT POPULATIONS 14

4.1 Immigrant Children and Adolescents 14

i
4.2 Clinical Populations 15
4.2.1 A Melbourne Clinical Sample 15
4.2.2 A Sydney Clinical Sample 15
4.2.3 Western Australian Clinic Samples 15

4.3 Conclusions 16

5 DIAGNOSTIC UTILITY 17

5.1 Behavioral and Emotional Problems 17

5.1.1 A Western Australian Sample 17
5.1.2 A Melbourne Sample 17
5.1.3 A Brisbane Sample 18

5.2 Anxiety Disorders 18

5.2.1 Identification of Anxiety Disorders 18
5.2.2 Measure of Anxiety Severity 18

5.3 Attention Deficit Hyperactivity Disorder 20

5.3.1 Diagnostic Utility 20
5.3.2 CBCL Scores Across DSM-IV ADHD Subtypes 20

5.4 Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) 21

5.4.1 Identification of an ODD and CD Factor 21
5.4.2 Symptom Level Among Children with ODD and CD 21

5.5 Depression 22
5.5.1 Development of a CBCL Depression Scale 22
5.5.2 Development of a YSR and CBCL Scale Equivalent to the CDI 22
5.5.3 Diagnostic Utility of Proposed Depression Scales 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 29
7.1.1 Mean Level of Problems in a Community Sample 29
7.1.2 Clinical Caseness 30
7.1.3 Mean Levels of Problems in Community and Clinic Samples 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 33

8.1.1 Academic problems 33
8.1.2 Bullying 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 71
11.7.4 Attention Problems and Hyperactivity 72
11.7.5 Depression 73
11.7.6 Delinquency and homelessness 74
11.7.7 Assessment Issues 74
11.7.8 Neuropsychological Assessment 75
11.7.9 Anxiety 76
11.7.10 Psychosocial Factors 77
11.7.11 Physical Illness 78
11.7.12 Sexual Abuse 80
11.7.13 Other 80

iv
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 2002 Version
CBCL/1½-5
CBCL/4-18 Cross informant scales CBCL/6-18
(caregiver/teacher form)
Behavior scales: Behavior scales: Behavior scales: Behavior scales:
Withdrawn Withdrawn Withdrawn Withdrawn/Depressed
Somatic Complaints Somatic Complaints Somatic Complaints Somatic Complaints
Anxious/Depressed Anxious/Depressed Anxious/Depressed Anxious/Depressed
Social Problems Social Problems Emotionally Reactive Social Problems
Thought Problems Thought Problems Aggressive Behavior Thought Problems
Attention Problems Attention Problems Attention Problems Attention Problems;
Delinquent Behavior Delinquent Behavior Sleep problems Rule-Breaking Behavior
Aggressive Behavior Aggressive Behavior Externalising problems Aggressive Behavior
Sex Problems (age 4-11) Externalising problems Internalising problems Externalising problems
Externalising problems Internalising problems Total problems scale Internalising problems
Internalising problems Total problems scale Total problems scale
Total problems scale
Competence scales: Competence scales: Competence scales: Competence scales:
Activities Activities Language Development Survey Activities
Social Social Social
School Total competence School
Total competence Total competence
DSM-IV oriented scales: DSM-IV oriented scales:
Affective Problems Affective Problems
Anxiety Problems Anxiety Problems
Pervasive Developmental
Somatic Problems
Problems
Attention Deficit/Hyperactivity Attention Deficit/Hyperactivity
Problems Problems
Oppositional Defiant Problems Oppositional Defiant Problems
Conduct Problems

1.2.2.3 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 18-
years 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 8-
factors 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 Morbidity Rates

3.1.1.1 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
Youth report 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

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 % Males Females
CBCL Scale
(n = 4083) (n = 2082) (n = 2001)
Broad band scales
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
Syndrome scales
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

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 6-
to 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 well-
being. 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 non-
clinical 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 non-
immigrant 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 borderline-
clinical, 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 A Melbourne Sample

5.1.2.1 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, post-
treatment, 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 pre-
treatment 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 follow-
up 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 DSM-
III-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 YSR-
CDI 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
Anxious/depressed
al. (1989)
Composite Addition of CBCL-NUR and YSR-CDI, divided by two

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 16-
years) 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 Conduct Hyperactivity Depression
Item Item content Item Item content Item Item content Item Item content
3. Argues 15. Cruel to animals 1. Acts too young 13. Confused
16. Cruelty 21. Destroys property 8. Can’t concentrate 14. Cries
22. Disobedient, home 43. Lying 10. Hyperactive 18. Harms self
23. Disobedient, school 72. Sets fires 23. Disobedient, school 30. Fears school
37. Fights 81. Steals at home 41. Impulsive 31. Fears doing bad
57. Attacks people 82. Steals at school 44. Bites fingernails 32. Has to be perfect
68. Screams 67. Runs away 45. Nervous 35. Worthless
86. Stubborn 101. Truancy 61. Poor school work 42. Alone
90. Swears 105. Alcohol, drugs 62. Clumsy 47. Nightmare
94. Teases 106. Vandalism 74. Shows off 50. Fearful
95 Tantrums 52. Guilty
97. Threatens 54. Overtired
56b. Headaches
75. Shy
77. Sleeps more
80. Stares blankly
91. Suicidal
100. Trouble sleeping
102. Underactive
103. Unhappy
111. Withdrawn
112. 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 non-
clinical, 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 14-
15 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 non-
clinical 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 5-
year 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 follow-
up: < $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
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41
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 H = Hyperactive
D = Depressed OC = Obsessive Compulsive
I = Immature U = Uncommon
S = Somatic SC-O = Schizoid Obsessive
SP = Sex problems C = Cruel
SZ = Schizoid H-WD = Hostile Withdrawal
A = Aggressive A-O = Anxious Obsessive
DQ = Delinquent D-W = Depressed Withdrawal
O = Obese 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 Small effect size Medium effect size Large effect size
1. Acts too young 3. Argues a lot 83. Stores up un- 96. Thinks about sex
4. Asthma 5. Behaves like needed things too much
10. Can’t sit still, opposite sex 112. Worrying
restless, hyperactive 8. Can’t concentrate 60. Plays with sex parts
12. Lonely 11. Too dependent too much
15. Cruel to animals 13. Confused 90. Swearing or
38. Is teased 14. Cries a lot obscene language
42. Likes to be alone 17. Daydreams
44. Bites fingernails 19. Demands attention Total Problem Score
48. Not liked 22. Disobedient at
51. Dizzy home
53. Overeating 26. Lacks guilt
56b. Headaches 29. Fears
56c. Nausea, feels 32. Needs to be perfect
sick 33. Feels unloved
59. Plays with sex 34. Feels persecuted
parts in public 35. Feels worthless
63. Prefers older 36. Accident prone
children 37. Fighting
76. Sleeps little 39. Hangs around
84. Strange behavior children who get into
91. Suicidal talk trouble
100. Trouble 40. Hears things that
sleeping aren’t there
101. Truancy 41. Impulsive
104. Unusually loud 43. Lying or cheating
105. Alcohol or 45. Nervous
drugs 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

47
 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 Girls Boys Girls Boys Girls
(n = 333) (n = 231) (n = 181) (n = 69) (n = 122) (n = 73)
Problem score 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)

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 Sydney USA Melbourne Sydney USA
(n = 333) (n = 300) (n = 458) (n = 231) (n = 300) (n = 488)
Problem score 24.6 32.4 (S>M) 24.3 23.2 30.6 (S>M) 23.1
Internalising 6.4 8.5 (S>M) 5.6 7.6 9.0 (S>M) 6.3 (M>A)
Externalising 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
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 Sydney USA Melbourne Sydney USA
(n = 303) (n = 250) (n = 564) (n = 142) (n = 250) (n = 604)
Problem score 19.3 27.7 (S>M) 22.5 (A>M) 17.9 29.8 (S>M) 22.0 (A>M)
Internalising 6.2 8.1 (S>M) 6.3 6.9 10.2 (S>M) 7.5
Externalising 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
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 Clinic group
(n=116) (n=23) (n=68)
Mean SD Mean SD 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 Clinic group
(n=117) (n=11) (n=32)
Mean SD Mean SD 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 Clinic group
(n=121) (n=23) (n=68)
Mean SD Mean SD 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 Clinic group
(n=120) (n=11) (n=32)
Mean SD Mean SD 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=628) (n=246) (n=267) (n=201) (n=1342)
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
Syndrome scale
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
Social Competence Scale
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

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)
YSR
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)

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 24
CBCL, TRF and YSR sample sizes vary owing to teacher and child response rates

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
YSR
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

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) 61.1 (10.8) 52.7 (9.7)

55
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 CBT CBT+FAM CBT CBT+FAM CBT CBT+FAM
CDI 9.92 (7.15) 6.94 (4.45) 2.35 (2.78) 3.06 (3.49) 8.00 (5.39) 6.75 (5.52)
FSSC-R 136.58 (22.96) 122.94 (23.82) 99.65 (23.28) 88.88 (16.03) 108.54 (17.90) 95.94 (10.21)
RCMAS 13.60 (5.74) 11.75 (6.10) 4.40 (4.06) 4.75 (4.58) 8.16 (6.66) 6.31 (5.86)
CBCL-I
70.22 (7.51) 66.00 (5.84) 50.19 (8.59) 50.11 (6.95) 50.44 (12.79) 55.56 (13.32)
Mother
Father 68.20 (6.78) 64.79 (9.31) 51.30 (9.00) 47.00 (7.39) 49.75 (12.39) 53.43 (16.48)
CBCL-E
Mother 59.22 (8.93) 54.94 (9.64) 45.67 (7.67) 47.67 (10.06) 46.22 (9.12) 45.06 (10.29)
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)
Total problems 39.6 (25.2) 43.8 (26.9) 62.1 (27.2) 16.1 (16.0) C > HI & I > N
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 .498
Stubborn, sullen,
86. .587
irritable
Swearing, obscene
90. .418
language
ODD items
82. Steals outside home .516
81. Steals at home .521
67. Runs away from home .586
43. Lying, cheating .476
72. Sets fires .367
101. Truancy, skips school .485
106. Vandalism .464
21. Destroys others’ things .452

57
15. Cruel to animals .434
37. Gets in many fights .491
Physically attacks
57. .727
people
16. Cruelty, bullying .635
105. Uses alcohol, drugs .449
97. Threatens people .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. Summary of item content
12. Lonely
103. Sad
11. Worrying
35. Feels worthless
13. Confused
33. Feels unloved
91. Suicidal talk
87. Moody
30. Fears school
14. Cries much
9. Obsessions
18. Harms self
8. Can’t concentrate
100. Can’t sleep
45. 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 4 5
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
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
YSR-CDI
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
YSR-DEPB
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
YSR-DEPG
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
Composite
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
Anxious/Depressed
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

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
Internalising (n = 55)
High score 42 27 20
Medium score 31 26 36
Low score 27 47 44
Externalising (n = 53)
High score 49 32 30
Medium score 28 32 45
Low score 23 36 25

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
Syndrome scale (>90 percentile)
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

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 16.7±3.7 16.1±3.7 3.3±1.6 5.5±2.2
Externalising scale 14.1±3.5 13.8±3.5 11.2±1.1 4.4±2.0
Internalising scale 18.2±3.8 16.1±3.7 3.7±1.9 9.4±3.0

14-15 year old males

Total problem scale 19.9±4.9 16.5±4.6 6.0±2.9 8.8±3.5
Externalising scale 17.7±4.6 19.9±4.9 5.6±2.8 6.9±3.2
Internalising scale 19.3±4.8 19.5±4.9 11.9±4.0 9.4±3.7

14-15 year old females

Total problem scale 15.9±4.0 11.7±3.5 9.2±3.3 9.1±3.1
Externalising scale 7.9±3.1 7.8±3.0 6.6±2.9 7.8±2.9
Internalising scale 9.4±3.3 5.2±2.4 12.0±3.7 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
Father score (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
Child score (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
Teacher score (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
Females
Mother score (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 (N = 42) (N = 32)
Total behavior score 16.0±2.1 63.3±4.7
Externalising score 8.0±1.1 31.9±2.5
Internalising score 7.2±1.0 25.1±2.1
Child score (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
Teacher score (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

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
14-15 year olds
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
Sydney cut-off scores
10-11 year olds
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
14-15 year olds
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

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
Chi-squared p < 0.01 p < 0.01 p < 0.01

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, 155-
164.

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, 453-
457.

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 (ADHD-
CT): 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.

73
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, 592-
602.

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, 652-
660.

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, 407-
414.

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, 1297-
1303.

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 obsessive-
compulsive 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, 142-
150.

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, E111-
E118.

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 self-
concept 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, 121-
124.

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, 31-
40.

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