The Child Behavior Checklist and Related Forms for Assessing Behavioral/Emotional Problems and Competencies

Abstract

After completing this article, readers should be able to:Primary care physicians who work with children must deal with a great variety of behavioral and emotional problems. The system described in this article provides low-cost, standardized assessment and documentation of such problems and requires little effort by the physician.Primary care physicians are under increasing pressure to obtain standardized documentation for the conditions they encounter. The most obvious pressures stem from managed care. Among the most frequently imposed expectations of primary care physicians are to: To fulfill these expectations, physicians need cost-effective procedures for obtaining, using, and transmitting information about patients.Children’s behavioral and emotional problems pose special challenges for meeting such managed care requirements. Certain types of behavioral problems, such as those ascribed to attention deficit hyperactivity disorder (ADHD), are widely publicized as candidates for medical management. Concerned parents, therefore, may request that pediatricians and family practitioners evaluate their children for ADHD. To assess ADHD and other behavioral and emotional problems, physicians need information from people who see children in their everyday contexts. Parents and parent-surrogates are the primary sources of such information for most children. Older children can contribute useful information about their own functioning. Teachers are especially important sources of information when children’s functioning in school is relevant, such as when ADHD is suspected.There are no litmus tests to determine precisely which children have behavioral or emotional disorders. Furthermore, even when a child’s behavior is clearly problematic, detailed documentation is needed to pinpoint the specific areas in which the child’s behavior deviates from norms for age and gender. Such documentation is needed for deciding what action to take, advising parents, communicating with mental health and special education personnel, and referring to specialists.The CBCL is a standardized form that parents fill out to describe their children’s behavioral and emotional problems. The version of the CBCL for ages 2 and 3 years (CBCL/2 to 3) can be completed by parents in about 10 minutes. The version for ages 4 to 18 years (CBCL/4 to 18) includes competence items and problems. The problem items can be completed by most parents in about 10 minutes, and the (optional) competence items require an additional 5 to 10 minutes. The CBCL is self-explanatory and can be filled out in a waiting room or can be sent home for completion. If a parent is unable to complete the CBCL independently, a receptionist or other staff member can read the items aloud and enter the parent’s answers while the parent follows along on a second copy. For parents whose English skills are poor but who can read other languages, translations are available in 58 languages.Figure 1 shows the CBCL/2 to 3 filled out for 3-year-old Adam Stern by his mother. For each problem item, parents circle 0 if the item is not true of their child, 1 if the item is somewhat or sometimes true, and 2 if the item is very true or often true. Problem items on the CBCL/4 to 18 resemble those on the CBCL/2 to 3, except that parents rate the CBCL/4 to 18 problem items for the preceding 6 months instead of the 2 months specified on the CBCL/2 to 3. Competence items on the CBCL/4 to 18 assess the child’s activities, social relations, and school functioning.The data obtained with the CBCL are summarized on a profile that displays the parent’s ratings of each item. The profile also displays the child’s standing on syndromes of problems that were derived from statistical analyses of CBCLs filled out for large numbers of clinically referred children. Each syndrome consists of problems that were found to occur concomitantly. Figure 2 displays the profile for Adam Stern that was scored from the CBCL/2 to 3 filled out by his mother.As illustrated in Figure 2, the CBCL/2 to 3 syndromes are designated in six areas: anxious/depressed, withdrawn, sleep problems, somatic problems, aggressive behavior, and destructive behavior. Adam’s score on each syndrome consists of the sum of numbers that his mother circled on the individual items that comprise the syndrome. The left side of the profile delineates the percentile of the national normative sample for each syndrome score. For example, Adam’s score on the anxious/depressed syndrome is at the 69th percentile, which means that 69% of the children in the national normative sample obtained scores at or below the score that Adam obtained.The broken lines on the profile shown in Figure 2 indicate a borderline range between the normal and clinical ranges. Scores that are below the bottom broken line (95th percentile) are in the normal range, and those that are above the top broken line (98th percentile) are in the clinical range. Scores between the broken lines are hig