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The Child Behavior Checklist for Ages

1.5–5 (CBCL/1½–5): Assessment and


analysis of parent- and caregiver-reported
problems in a population-based sample of
Danish preschool children
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SOLVEJG KRISTENSEN, TINE BRINK HENRIKSEN, NIELS BILENBERG

Kristensen S, Henriksen TB, Bilenberg N. The Child Behavior Checklist for ages 1.5–5
(CBCL/1½–5): Assessment and analysis of parent- and caregiver-reported problems in a
population-based sample of Danish preschool children. Nord J Psychiatry 2010;64:203-209.

Background: Psychometric instruments are used increasingly within research and clinical settings,
and therefore standardization has become an important prerequisite, even for investigating very
young children. Currently, there are no standardized psychometric instruments available for assess-
ment of preschool children in Denmark. Aims: The aim was to achieve Danish national norm scores
For personal use only.

for the Child Behavior Checklist for Ages 1½–5 (CBCL/1½–5) and the Caregiver Report Form
(C-TRF). Methods: The study was based on an age- and gender-stratified cohort sample of 1750
children aged 1½–5 years born at Aarhus University Hospital, Denmark. The CBCL/1½–5 and
C-TRF were mailed to parents, who were asked to pass on the C-TRF to the preschool care-
giver. The national standard register data gave access to information on socio-economic status,
family type, ethnicity and parental educational level for analysis of participation and representa-
tion. Results: A total number of 850 (49%) families replied, and 624 caregivers replied. The mean
Total Problem Score (TPS) with 95% confidence interval was 17.3 (16.3–18.3) for parents’ reports.
Age-and gender-specific scale score findings for Danish preschoolers and schoolchildren were compa-
rable. No differences were found in the mean TPS within subgroups related to parental socio-demo-
graphic features. Conclusion: On the basis of a large sample, Danish national norm scores and
profiles of the ASEBA Preschool Forms were established; the scores of descendents must, however,
be assessed with some caution. With this reservation, the CBCL/1½–5 and C-TRF forms are now
available in Danish and can be recommended for use in clinical and research settings.
• CBCL 1½–5, Epidemiology, Normative data, Preschool Child, Psychometrics.

Solvejg Kristensen, Department of Child and Adolescent Psychiatry, Research unit, University of
Southern Denmark, 5000 Odense C, Denmark, E-mail: solkri@rm.dk; Accepted 29 October 2009.

O ver the last decade, the use of psychometric instru-


ments has increased within research and clinical set-
tings. As a result, numerous checklists, assessment scales
languages (1). The instruments are designed to capture both
similarities and differences in how children and youngsters
behave and function under different conditions in different
and structured interviews have been developed, making social settings. Achenbach and his co-workers developed
validation and standardization important prerequisites for the ASEBA instruments through decades of research and
researchers throughout the psychiatric field. Only a limited practical experience and described them in their early
number of these instruments have become the subject of papers and in the manuals (2–6). The manuals present the
international interest. One of them is the Achenbach Sys- validation and standardization procedures in large Ameri-
tem of Empirically Based Assessment (ASEBA), which can samples. The ASEBA forms for school-aged children
has influenced the worldwide standard for multi-informant (CBCL/4–18) have well-documented reliability and valid-
assessment of behavioural, emotional and social function ity, and they have been standardized and validated in
across different age spans. The instruments have been used numerous countries throughout the world (7–16). Cross-
in some 6500 studies and translated into more than 80 cultural comparisons have also been made (17–21).

© 2010 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As) DOI: 10.3109/08039480903456595
S. KRISTENSEN ET AL.

In 2000, the ASEBA Preschool Forms & Profiles was The CBCL/1½–5 requests supplementary information
introduced. It includes a Parent Report Form (Child Behav- about the health of the child. The C-TRF requests informa-
ior Checklist for Ages 1.5–5; CBCL/1½–5), a Caregiver- tion about kind of day care and the role of the respondent
Teacher Report Form (C-TRF) and a Language Development in relation to the child, including how well the respon-
Survey (LDS). It is an extension of the former CBCL/2–3 dent knows the child and in which context the child is
based on the CBCL/4–18 (6, 22). The CBCL/2–3 has been evaluated.
used to assess substantial samples in the Netherlands,
Finland, Iceland, Canada and the USA (23, 24). Scores and scales on CBCL and C-TRF
In Denmark, the CBCL/4–16 was tested and standard- Scores on the Preschool Forms are hierarchically ordered.
ized in 1999 (7). It is now used for assessment and detec- According to the American standardization, the lowest level
tion of early signs of psychopathology within clinical comprises the 100 problem items, and each item is scored
settings, quality assessment and as outcome measure of 0–1–2 on specific aspects of behavioural, emotional and
child behaviour in epidemiological studies (25, 26). For
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social functioning. The next level comprises psychiatric


the same purposes, standardized instruments for even younger syndrome scales, derived by applying exploratory and
children are needed. confirmatory factor analytic methodology. The next hierar-
chical level comprises the 36-item Internalising and 24-item
Aim Externalising Scales. Internalizing and externalizing prob-
The aim of this study was to achieve Danish national lems are not mutually exclusive. The highest level in the
norm scores of the ASEBA Preschool Forms by assessing hierarchy comprises the Total Problem Scale. (6)
and analysing parent- and caregiver-reported behavioural, The Total Problem Scale score (TPS) is computed by
emotional and social function using the CBCL/1½–5 and adding the sum of all 0–1–2 scores on the 99 specific
the C-TRF. problem items and the highest score of 1 or 2 on any addi-
tional problems entered for item 100. Thus, the TPS ranges
from 0 to 200.
Material and methods
For personal use only.

For the purpose of relating symptoms to formal diagnos-


Population tic criteria and for cross-cultural comparisons, five different
The study was based on a stratified cohort sample of 1750
Diagnostic and Statistical Manual for Mental Disorders
children aged 1½–5 years born at Aarhus University Hospi-
(DSM)-Oriented Scales–Affective Problems, Anxiety
tal between 1997 and 2002. The Aarhus Birth Cohort was
Problems, Pervasive Developmental Problems, Attention
established in 1989, at the time of the study retrieving infor- Deficit/Hyperactivity Problems and Oppositional Defiant
mation on about 5000 pregnant women and their newborns Problems–were constructed by Achenbach & Rescorla (6).
per year. Two random samples based on 1250 and 500 chil- Sixteen experienced health professionals from nine dif-
dren were drawn from the birth cohort in spring 2003 and ferent cultures judged items to be consistent with
2004, respectively. The two study samples ensured that the DSM-IV diagnostic categories, meaning that the scales
full study population consisted of 175 boys and 175 girls in reflect overlaps between DSM-IV criteria and item rat-
each of the age groups: 1½, 2, 3, 4 and 5 years of age. All ings for different DSM categories. High scores on these
children were between 5 and 7 months from their birthday scales indicate a need for further clinical assessment.
at the time of participating, meaning that e.g. a 2-year-old
We present Danish scores on the following scales: Total
child would be 2 years and 5–7 months old.
Problem Scale, Internalising and Externalising Scales,
and DSM-Oriented Scales.
CBCL/1½–5 and C-TRF
The CBCL/1½–5 and C-TRF are similarly constructed to
cover an empirical range of behavioural, emotional and Translation of CBCL and C-TRF
social function problems. Both forms comprise 100 problem Because of the overlaps of items on the CBCL/4–16 and
items: 99 closed items and one open-ended item, which the Preschool Forms, the translation for the CBCL/4–16
requests the respondent to add any additional problems not was used for translating most items. Initially the CBCL/4–
previously listed. The CBCL/1½–5 is completed by the par- 16 was translated from American English into Danish
ents or other adults living with the child in a family-like and then re-translated by another linguist back into
setting, whereas day care providers or others minding the American English (7). Items that were changed during
child during the daytime complete the C-TRF. The respon- this procedure were discussed in the research group and
dent is requested to rate each item, based on the preceding the most meaningful and correct expressions chosen for
two months, as 0 for not true, 1 for somewhat or sometimes the Danish translation. Items appearing only on the Pre-
true, and 2 for very true or often true. The C-TRF substi- school Forms were translated by professional linguists
tutes 17 items pertinent to family situations for items specific in cooperation with clinicians, and differences in phras-
to group situations. ing of the items were resolved in the research group by

204 NORD J PSYCHIATRY·VOL 64·NO 3·2010


THE CHILD BEHAVIOR CHECKLIST FOR AGES 1½–5

discussion, according to agreement with Achenbach & DSM-Oriented Scales were described by mean, standard
Rescorla (6). deviation (s) and 95% confidence intervals (95% CI). Inter-
nal consistency of the scales was analysed using Cronbach
Other data sources alpha (α).
All persons living in Denmark are registered according to Analyses of participation and representation were carried
numerous variables via the unique Danish personal iden- out using chi-square tests and t-tests. Analyses of parental
tification number (CPR) in the Danish Civil Registration educational level, attachment to the labour market and age
System (CRS). At the time of the study, the CPR gave were performed for mothers and fathers separately, whereas
access to information on: status of parental education and analysis of family type was performed related to the child.
occupation, family structure, and both parents’ age and Comparisons across age, gender, demographic factors
native country. and scale scores were made using non-parametric statis-
Information from the CRS was obtained for the moth- tical tests (Mann–Whitney and Kruskal–Wallis). The level
ers and fathers of the 1750 possible participants and for of two-sided statistical significance was set at P⬍0.05.
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a sample of 21,125 gender- and age-matched children


from the background population. Ethics
Information on occupational status was dichotomized All families approached gave their written informed con-
into whether the parent was 1) in a regular job, on tempo- sent when completing the CBCL/1½–5. By delivering the
rary leave, an assistant partner or a student (i.e. attached C-TRF to the child’s caregiver, the parents accepted that
to the labour market), or was 2) out of work, a pensioner, the caregiver participated and returned the form directly
rehabilitee or otherwise not attached to the labour market. to the researchers.
Educational status was categorized into three groups No returned checklists resulted in contacting the families
according to the parents’ educational qualifications: 1) less to advise them to seek help for the child.
than or equal to 10 years of education (primary school), 2)
more than 10 but less than 13 years of education (high
For personal use only.

school or short professional education), or 3) more than Results


13 years of education (longer professional education or Participation
university degree). Family type was assessed according A total of 850 families replied sufficiently to the
to National Register information on the number of adults CBCL/1½–5, whereas 624 caregivers replied to the C-TRF.
living at the address of the child into single-parent family Both forms were obtained for 609 children. The overall
or two-parent family. Parental age was dichotomized into parental responds rate was 49%. Participation was equally
two groups: 1) parents younger than 35 years and 2) distributed within gender and child age groups (P⫽0.75).
parents aged 35 or older. Respondents of the CBCL/1½–5 were 78% mothers,
11% fathers and 11% others. The informants of the CTR-F
Collection of information from parents were 77% caregivers from kindergartens, 21% caregivers
and caregivers from private or public day care, and 2% others. A total of
A letter of information, the CBCL/1½–5 and the additional 12 participating children (1.5%) were descendents.
form were mailed to each family. The families were asked According to parent information, 56 of 838 (7%)
for one parental reply per family. It was optional who filled children had been referred to professional help within the
in the questionnaire: the mother, the father, somebody with last year, e.g. a child psychiatrist, psychologist, physio-
a parent-like relation or a combination of respondents. The therapist or logopaedist.
letter also contained an open envelope with information and
the C-TRF for the caregiver of the child; the parents were Analysis of representation and attrition
asked to pass on this envelope. The informants of the two Analyses of representation and attrition were made to inves-
checklists were requested to complete the forms without tigate possible selection bias and external validity (27).
consulting each other and to return them directly to the Demographic information on family structure, status of
researchers. Non-responders received two mailed reminders. parental education and occupation, and parents’ age was
dealt with in both analyses.
Statistical analysis Analysis of representation was performed by compar-
Statistical analyses were carried out by SPSS version ing the study sample’s demographic information with infor-
14.0 for Windows. mation on an age- and gender-matched random sample
All scores were computed according to Achenbach and of the Danish background population (n⫽21,125). In the
Rescorla’s instructions in the manual for the Preschool analyses of attrition, demographic information on respon-
Forms (6). Raw scores on the Total Problem Scale, Inter- dents (n⫽850) was compared with that of non-respondents
nalising and Externalising Scales and scores on the five (n⫽900).

NORD J PSYCHIATRY·VOL 64·NO 3·2010 205


S. KRISTENSEN ET AL.

Results from the analysis of representation showed that The 12 participating descendents had a mean TPS of
in the study sample both mothers and fathers more fre- 35.6 (19.9–51.3), whereas it was 16.8 (15.8–17.7) for the
quently had more than 13 years of education (longer pro- 828 non-descendents.
fessional education or university degree), P⬍0.01. Also, Boys obtained a significantly higher mean TPS than
in the study sample, the fathers were more frequently girls, according to caregivers P⬍0.01. The mean TPS
not attached to the labour market than in the background was higher among the youngest children of 1½–2 years
population, P⬍0.01. than among 3–5-year-olds; the difference was statistically
Results from the analysis of attrition showed that in significant for caregiver ratings only, P⫽0.02.
non-responding families (n⫽850) both fathers and mothers The Internalising Scale comprises problems like emotional
were more frequently not attached to the labour marked, reactivity, anxiety/depression, somatic complaints without
P⬍0.05, than in responding families (n⫽900). medical cause and withdrawal from social contacts. The
Extensive investigation of the characteristics of a sub- Externalising Scale comprises problems that mainly involve
sample of n⫽300 of the 2004 sample showed that non- conflicts with other people, and with their expectations
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participation was associated with parental self-reported of the child, such as attention problems and aggressive
attitudes towards ethical issues related to CBCL/1½–5, behaviour.
and to poor parental knowledge about child well-being Mean scale scores on the TPS, and the Internalising
and behaviour in general (27). and Externalising Scales for both checklists are presented
in Tables 1 and 2, also showing gender- and age-strati-
Mean scores on the Total Problem Scale and the fied scale scores. No statistically significant differences
Internalising and Externalising Scales were found in any of the investigated age or gender
The TPS is one of the main outcomes in the literature mean Internalising scale scores.
regarding ASEBA Forms. The distribution of scores on the Parents rated externalizing problem behaviour higher
TPS showed practically identical patterns for parents and than caregivers, P⬍0.01. Boys’ externalizing behaviour
caregivers, illustrated in Fig
Fig.1. was scored higher than girls’ by caregivers, P⫽0.01.
Mean Externalising Scale scores were statistically higher
For personal use only.

The mean TPS for dichotomized subgroups related to


the mother’s respectively father’s 1) occupational status, among the youngest children of 1½–2 years than among
2) educational status, 3) family type and 4) parental age 3–5-year-olds, both according to the ratings of parents
was investigated. The four groups were dichotomized as and caregivers, P⬍0.01.
described above under Other data sources. Within each
of the four groups, we found no significant differences in Scores on DSM-Oriented Scales
TPS (P-values ranging from 0.29 to 0.82). To advance the clinical use of the ASEBA preschool
No statistically significant differences were found in Forms the five DSM-Oriented scales were constructed
TPS between the profiles of children whose mothers (6). Clinically the DSM-Oriented Scales can be used to
(n⫽658) and fathers (n⫽90) filled in the CBCL/1½–5, support assessment of referred children. The mean and
P⫽0.26. standard deviation in the normative population guide the

Fig. 1. Distribution of scores on the Total Problem Scale (TPS) for Child Behavior Checklist for Ages 1½–5 (CBCL/1½–5) and the
Caregiver-Teacher Report Form (C-TRF).

206 NORD J PSYCHIATRY·VOL 64·NO 3·2010


THE CHILD BEHAVIOR CHECKLIST FOR AGES 1½–5

Table 1. Gender-stratified scale scores for the Child Behavior Checklist for Ages 1½–5 (CBCL/1½–5) and the Caregiver-Teacher Report
Form (C-TRF).

Checklist Gender n Mean s 95% CI Gender comparison Cronbach α

Total Problem Scale scores


CBCL/1½–5 Boys and girls 850 17.3 15.3 16.3–18.3 – 0.94
Boys 424 17.5 14.5 16.1–18.9 0.93
P⫽0.45
Girls 426 16.7 16.1 15.4–18.1 0.95
C-TRF Boys and girls 624 13.9 15.7 12.7–15.1 – 0.95
Boys 308 15.6 13.8 13.8–17.4 0.95
P⬍0.01
Girls 316 12.2 15.2 10.5–13.9 0.95
Internalising Scale scores
CBCL/1½–5 Boys and girls 850 3.9 5.1 3.5–4.2 – 0.87
Boys 424 3.8 4.6 3.2–4.2 0.84
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P⫽0.51
Girls 426 4.0 3.3 3.5–4.5 0.89
C-TRF Boys and girls 624 4.2 5.6 3.8–4.7 – 0.88
Boys 308 4.6 5.6 4.0–5.3 0.87
P⫽0.08
Girls 316 3.8 5.5 3.2–4.4 0.89
Externalising Scale scores
CBCL/1½–5 Boys and girls 850 6.7 6.0 6.3–7.1 – 0.89
Boys 424 6.8 6.1 6.3–7.4 0.89
P⫽0.42
Girls 426 6.5 5.8 5.9–7.1 0.88
C-TRF Boys and girls 624 4.8 6.1 4.3–5.3 – 0.90
Boys 308 5.8 6.6 4.7–6.2 0.91
P⫽0.01
Girls 316 4.2 5.6 3.6–4.8 0.90

s, standard deviation; CI, confidence interval.


For personal use only.

clinician concerning the degree of psychopathology and In this Danish study, the CBCL for Ages 1½–5 was
the successful treatment. completed by parents of 850 children and by caregivers
Table 3 shows Danish figures of parent- and care- of 624 children, giving a parental participation rate of
giver-reported DSM-Oriented Mean Scale scores. 49%. A similarly low participation rate among parents of
preschool-aged children has previously been found on
Iceland using the former CBCL version for 2–3-year-old
Discussion children (10).
Assessment of the preschool child generally involves The analysis of representation, comparing the sample
variations in behaviour displayed by most children to of the 1750 children to a matched sample of the Danish
some extent during their development. The behavioural background population using socio-demographic vari-
and emotional problems vary in severity and duration, ables, shows possible selection bias regarding parental
and may also be more prevalent in specific settings. occupational and educational status. However, because
Although we do not know at present how predictive no significant differences were found in the mean TPS
parent- and caregiver-reported problems are for psy- across these variables, as published in a recent paper
chopathology later in life, it is still vital to identify and comparing features of responders and non-responders
offer early and adequate help to preschool children (27), we consider the possible selection bias of minor
presenting problems of concern, as both the child, importance, but we want to emphasize that further stud-
its parents, siblings and caregivers may suffer consider- ies to validate the Danish norm scores are planned.
able distress, and secondary problems may arise as a The present study is the first publication on national
consequence. norms of the CBCL/1½–5 and C-TRF from outside the
Psychometric instruments facilitate early identification USA. The study design offers some possibility of com-
of problem behaviour in the preschool child. The CBCL parison with American scores, although different ways of
for Ages 1½–5 provides a structured overview of behav- sampling were used to achieve the national norms
iour, social and emotional function. Generally speaking, scores.
psychometric instruments for use in clinical work and in Mean TPS was 17.3 (16.3–18.3). Both parents and
research should balance the following demands: reliable caregivers rated declining TPS with increasing age. This
and valid data collection, and feasibility for families and trend has also been found in the USA, both for pre-
caregivers, ensuring a sufficiently high representative school and school-aged children, and for Danish school-
cooperation and participation. aged children (4, 6, 7). No differences were found in the

NORD J PSYCHIATRY·VOL 64·NO 3·2010 207


S. KRISTENSEN ET AL.

Table 2. Age-stratified scale scores for Child Behavior Checklist for Ages 1½–5 (CBCL/1½–5) and the Caregiver-Teacher Report Form
(C-TRF).

Age in Age group


Checklist years n Mean s 95% CI comparison

Total Problem Scale scores


CBCL/1½–5 1½–2 353 18.5 13.0 17.2–19.9
P⫽0.13
3–5 497 16.1 15.0 14.8–17.4
C-TRF 1½–2 250 15.6 16.1 13.6–17.6
P⫽0.02
3–5 374 12.7 15.4 11.1–14.2
Internalising Scale scores
CBCL/1½–5 1½–2 353 3.4 4.0 3.0–3.9
P⫽0.24
3–5 497 4.2 5.8 3.7–4.7
C-TRF 1½–2 250 4.2 5.5 3.5–4.9
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P⫽0.86
3–5 374 4.2 5.7 3.7–4.8
Externalising Scale scores
CBCL/1½–5 1½–2 353 7.8 5.5 7.2–8.3
P⬍0.01
3–5 497 5.9 6.1 5.4–6.5
C-TRF 1½–2 250 5.9 6.3 5.1–6.7
P⬍0.01
3–5 374 4.1 5.9 3.5–4.7

s, standard deviation; CI, confidence interval.

TPS related to parental age, educational status, occupa- children, which is parallel to findings of the younger
tion or family type. Boys had a significantly higher mean groups of Danish school-aged children and the younger
TPS than girls according to the ratings of caregivers; this groups of American children who scored higher than the
is equivalent to the findings in the American norm scores older groups of children (4, 6, 7).
For personal use only.

(4, 6). According to parents’ rating, boys also had a slightly The mean TPS of descendents was twice as high as
higher mean TPS than girls. This finding was not statis- for non-descendents; however, the number of participating
tically significant, though it may have clinical relevance. descendents was very low and the result must be interpreted
Comparison of national norm scores is not included in and used with great caution.
this paper. A large cross-cultural comparison study of In a recent cross-national comparison of national
ASEBA preschool data, where Danish data are included is mean TPS scores obtained using the school age version
in preparation. Danish national ASEBA preschool norm of the CBCL, the Danish national norm score was in the
scores are significantly lower than the established American lower third of the 31 countries investigated (20). Thus it
norm scores, which also was the case for school age remains uncertain whether the differences found are
children (20). related to true cultural differences, i.e. whether they
A higher mean TPS was found for the youngest chil- reflect more problem behaviour among descendents, or
dren of 1½–2 years than among the older 3–5-year-old whether they reflect differences in how informants

Table 3. DSM-oriented scale scores for Child Behavior Checklist for Ages 1½–5 (CBCL/1½–5) and the Caregiver-Teacher Report
Form (C-TRF).

Scale (scoring range) Mean s 95% CI Cronbach α

Parent-reported DSM-oriented Scale scores (n⫽850)


Affective Problems (0–20) 1.1 1.6 0.9–1.2 0.62
Anxiety Problems (0–20) 1.6 1.9 1.5–1.8 0.65
Pervasive Development Problems (0–26) 1.6 2.3 1.4–1.7 0.72
Attention Deficit/Hyperactive Problems (0–12) 2.3 2.2 2.2–2.5 0.75
Oppositional Defiant Problems (0–12) 2.3 2.1 2.2–2.4 0.76
Caregiver-reported DSM-oriented Scale scores (n⫽624)
Affective Problems (0–20) 0.97 1.9 0.9–1.1 0.75
Anxiety Problems (0–20) 1.3 1.8 1.1–1.4 0.64
Pervasive Development Problems (0–26) 1.8 2.6 1.6–2.0 0.76
Attention Deficit/Hyperactive Problems (0–12) 1.8 2.3 1.6–1.9 0.79
Oppositional Defiant Problems (0–12) 1.3 2.0 1.2–1.5 0.81

s, standard deviation; CI, confidence interval.

208 NORD J PSYCHIATRY·VOL 64·NO 3·2010


THE CHILD BEHAVIOR CHECKLIST FOR AGES 1½–5

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For personal use only.

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