CBCL in the assessment of psychopathology in Finnish children with intellectual disability

CBCL in the assessment of psychopathology inFinnish children with intellectual disability

Terhi Koskentaustaa,*, Matti Iivanainenb,c, Fredrik Almqvistd

aDepartment of Psychiatry, Central Hospital of Paijat-Hame,

Keskussairaalankatu 7, 15850 Lahti, FinlandbDepartment of Child Neurology, Hospital for Children and Adolescents,

University of Helsinki, FinlandcRinnekoti Research Center, Espoo, Finland

dDepartment of Child Psychiatry, Hospital for Children and Adolescents,

University of Helsinki, Finland

Received 12 June 2003; received in revised form 7 November 2003; accepted 16 December 2003

Abstract

Structured checklists have been used to supplement psychiatric assessment of children

with normal intelligence, but for children with intellectual disability, only a few checklists

exist. We evaluated the Child Behavior Checklist (CBCL) in the assessment of psycho-

pathology in Finnish children with intellectual disability. The CBCL was completed by

parents or other carers of 90 children aged 6–13 years. Of the 118 CBCL problem items, the

lowest scores were for ‘Suicidal talks’ and ‘Alcohol, drugs’, and the highest score for ‘Acts

too young’. Total Problem, Internalizing, and Externalizing scores were highest among

children with moderate intellectual disability and lowest among those with profound

intellectual disability. Externalizing scores were significantly higher among children with

mild or moderate intellectual disability than among those with severe or profound

intellectual disability. Compared with the original normative samples, Total Problem scores

were higher in the present study. With a T-score cut-off point of 60, the rated frequency

of psychiatric disorders was 43%. We conclude that, despite certain limitations, the CBCL

can be used in the assessment of psychopathology among children with mild intellectual

disability but is less reliable for thosewithmoderate, severe,orprofound intellectualdisability.

# 2004 Elsevier Ltd. All rights reserved.

Keywords: Finnish children; psychopathology; intellectual disability; assessment; Child Behavior

Checklist

Research in Developmental Disabilities

25 (2004) 341–354

0891-4222/$ – see front matter # 2004 Elsevier Ltd. All rights reserved.

doi:10.1016/j.ridd.2003.12.001

* Corresponding author. Tel.: þ358-3-6336179.

E-mail address: [email protected] (T. Koskentausta).

1. Introduction

While emotional and behavioral problems are frequent among children with

intellectual disability (Bregman, 1991; Dykens, 2000), communication distur-

bances and other handicaps complicate the assessment of psychopathology in

these children. Structured checklists have been used to supplement psychiatric

assessment of children with normal intelligence, but for children with intellectual

disability, only a few checklists exist. Despite some restrictions in their applic-

ability, certain instruments for children with normal intelligence have been

applied in the assessment of children with intellectual disability.

The Child Behavior Checklist (CBCL; Achenbach, 1991) is a widely used

instrument in the assessment of emotional and behavioral problems of children

and adolescents. However, it has been used less often among children and

adolescents with intellectual disability. Hatton et al. (2002) found in a series

of 59 boys with Fragile-X syndrome that 49% had borderline or clinical problem

behavior. In children and adolescents with Down (n ¼ 23) and Fragile-X (n ¼ 12)

syndrome, Bargagna, Canepa, and Tinelli (2002) observed differences between

behavior profiles of these groups. The CBCL competence scores in both groups

were lower than average. Dekker, Koot, van der Ende, and Verhulst (2002)

reported that children with intellectual disability had significantly higher mean

scores on all CBCL scales than children without intellectual disability. In their

study, almost 50% of children with intellectual disability had a total problem

score in the deviant range compared with 18% of children without intellectual

disability.

The CBCL and the Psychopathology Instrument for Mentally Retarded Adults

(PIMRA) total scores have been found to be closely intercorrelated; likewise, the

CBCL Internalizing and Externalizing scores correlate with the PIMRA total

scores (Masi, Brovedani, Mucci, & Favilla, 2002).

The factorial validity of the CBCL has been evaluated by Borthwick-Duffy,

Lane, and Widaman (1997), who examined scores from the CBCL for 67 children

and adolescents with mental retardation. This factor analysis failed to confirm the

presence of the five first-order factors from the CBCL in their sample but did

provide evidence of more general broad-banded syndromes of Internalizing and

Externalizing problem behavior. Their results support the use of the CBCL for

children with intellectual disability.

The reliability of the CBCL for children with mild mental retardation has been

evaluated by Embregts (2000) using data on 42 children and youths. At item level,

mean kappas for inter-rater and test–retest reliability were .267 and .25, respec-

tively. At syndrome level, mean intra-class correlations for inter-rater and test–

retest reliability were .493 and .775, respectively. Embregts suggested that the

CBCL may not always represent a reliable checklist for the assessment of

psychopathology among children and youth with mental retardation.

Taking into account these disparate conclusions, our aim was to evaluate the

Finnish translation of the CBCL in the assessment of psychopathology in a

Finnish population of children with intellectual disability.

342 T. Koskentausta et al. / Research in Developmental Disabilities 25 (2004) 341–354

2. Method

2.1. Subjects

The subjects comprised children with intellectual disability born in 1982–1988

and residing in 1995 in the catchment area of the Paajarvi Rehabilitation Center,

Finland. The Paajarvi Rehabilitation Center provides services for persons with

intellectual disability residing in its catchment area, which includes 25 munici-

palities. Five of these are towns, with populations ranging from 16,000 to 95,000

inhabitants. The remaining 20 are smaller rural municipalities. The total popula-

tion base of this area in 1995 was about 337,000 inhabitants, approximately

28,000 of whom were born in 1982–1988.

The subjects were sought and identified from the patient register of the Paajarvi

Rehabilitation Center and regional hospitals and special schools. The number of

identified subjects was 149. The characteristics of the 90 males and 59 females are

presented in detail in Table 1. The subjects are presumed to include almost all

children with intellectual disability of the age group in the area. However, six

Table 1

Comparison of respondents (n ¼ 90) and non-respondents (n ¼ 59) according to sex, age, level of

intellectual disability, and presence of psychiatric disorders based on case files

Characteristic Respondents Nonrespondents

n Percent n Percent

Sex

Male 55 61.1 35 59.3

Female 35 38.9 24 40.7

100 100

Age

6–11 years 71 78.9 46 78

12–13 years 19 21.1 13 22

100 100

Level of intellectual disability

Mild 53 58.9 28 47.5

Moderate 17 18.9 13 22

Severe 11 12.2 7 11.9

Profound 9 10 11 18.6

100 100

Psychiatric disorder

No psychiatric disorder 60 66.7 42 71.2

Pervasive developmetal disorders (F84) 9 10 10 16.9

Hyperkinetic disorders (F90) 8 8.9 1 1.7

Other specified disordersa 4 4.4 1 1.7

Unspecified disorders (F99) 9 10 5 8.5

100 100

a One depression (F33), one eating disorder (F50), one conduct disorder (F91), and one emotional

disorder (F93) in the respondent group, and 1 emotional disorder (F93) in the non-respondent group.

T. Koskentausta et al. / Research in Developmental Disabilities 25 (2004) 341–354 343

additional children later identified as having intellectual disability were not

included.

2.2. Instrument

The assessment of psychopathology was based on the CBCL. The CBCL

(Achenbach, 1991) consists of competence items and 118 behavior problem

items. Behavior problem statements are scored by the parent on a three-level rating

scale, where 0 ¼ not true, 1 ¼ somewhat or sometimes true, and 2 ¼ very true or

often true. The checklist provides the Total Competence score and the Total

Problem score. The competence scales consist of Activities, Social, and School

Scales. The problem syndromes identified in the CBCL have been grouped by high-

order factor analyses into Internalizing and Externalizing dimensions of behavior.

The Internalizing factor includes the three syndromes of Withdrawn, Somatic

Complaints, and Anxious/Depressed, and the Externalizing factor the two syn-

dromes of Delinquent Behavior and Aggressive Behavior. In addition, four syn-

dromes known as Social Problems, Thought Problems, Attention Problems, and Sex

Problems are included in neither the Internalizing nor the Externalizing scales.

The test–retest reliability of the CBCL is high. The overall intraclass correla-

tion coefficient (ICC) is .996 for competence items and .952 for problem items.

The test–retest reliability for competence scales is .87 and for problem scales .89.

Inter-rater reliability between parents is .89 for competence scales and .65–.75 for

problem scales (Achenbach, 1991).

2.3. Procedure

The CBCL was mailed to the parents or other carers of 149 children. Completed

CBCLs were returned by parents or other carers of 93 children. Three checklists

were excluded because they were incomplete or unreliably completed. Thus,

checklists of 90 children were included. Of these, 82 were completed by parents

or foster parents,2 by othercarers, 2 by parents and teacher together, and 4 by teacher

alone. The distribution of sex, age, level of intellectual disability, or presence of a

psychiatricdisorderaccordingtocasefileswasnotsignificantlydifferentbetweenthe

90 respondents and the 59 non-respondents (Table 1).

In the analysis of results, the distribution of scores for individual problem items as

well as the scores for Competence Scales (Activities, Social, School, and Total

Competence scores) and Problem Scales (Total Problem score, Internalizing score,

and Externalizing score) was calculated. The cut-off point for the Total Problem

scoreforpsychiatricdisorderswas60,assuggestedbyAchenbach(1991).Theresults

were compared with the original CBCL normative samples (Achenbach, 1991).

To correlate the results of the CBCL with other checklists, the parents or carers

of the children were asked to complete the Developmental Behavior Checklist

(DBC; Einfeld & Tonge, 1994) and the AAMD Adaptive Behavior Scale (ABS;

Nihira, Foster, Shellhaas, & Leland, 1974). Completed DBCs were received for 80

and ABSs for 81 of the 90 children for whom the CBCL was completed.


Information on psychiatric diagnoses and symptoms was obtained from the

patient register and each case file. This information was analyzed by the first

author (T.K.). Previous psychiatric diagnoses were recorded and re-evaluated

according to information in case files. Some of the case files of the children with

no previous psychiatric diagnoses included information according to which the

child could be regarded as having a psychiatric disorder. The psychiatric

diagnoses were assessed based on ICD-10 criteria (Diagnostic Criteria for

Research), and the main categories are presented in Table 1.

2.4. Measurement of IQ range

The level of intellectual disability was defined in accordance with the ICD-10

criteria by intelligence quotient (IQ) as follows: IQ 50–69 as mild, IQ 35–49 as

moderate, IQ 20–34 as severe, and IQ < 20 as profound. Information on the level

of intellectual disability was obtained from case files. Psychological examinations

had previously been done for 84 children, and the tests most often used were

Wechsler Intelligence Scales for Children—Revised (WISC-R), Merrill–Palmer

Scale of Mental Tests, Leiter International Performance Scale, Cattell Infant

Intelligence Scale, and Vineland Social Maturity Scale.

Results of cognitive assessments were unavailable for six children, all of whom

presumablyhadintellectualdisability.Fourchildrenhadamotorandcommunication

disability due to cerebral palsy or inherited metabolic disease, and thus, could not be

tested. One child had Down syndrome and one child, for whom a psychological

examination had previously been performed but results were unavailable, had

intellectual disability of unknown etiology. All information in case files (e.g., motor,

communication, and self-help skills) was used to evaluate the level at which the

children operated. The AAMD Adaptive Behavior Scale (Nihira et al., 1974) was

completed by the parents of five of these children, and the score of the personal

independence part of the scale was consistent with the level of intellectual disability

determined as outlined above. The evaluated level of intellectual disability of these

six children was mild for 2, severe for 1, and profound for 3.

2.5. Data analysis

Statistical comparison was based on chi-square tests, Fisher’s exact tests,

unpaired t-tests, and single sample t-tests. Correlations with the ABS and the DBC

were calculated by simple linear regression.

3. Results

3.1. Competence scores

The responses to the competence items, especially the school scale, were

incomplete. Because of missing information in checklists, the Total Competence


score could be calculated for only 47% of children. Of the acceptable scores, no

significant differences were observed between males and females (Table 2).

Compared with the original CBCL normative samples (Achenbach, 1991), all

competence scores were significantly lower in our sample.

3.2. Problem item scores

Of the 118 problem items, 2 were scored as 0 for all of the children. These

items were ‘Suicidal talks’ and ‘Alcohol, drugs’. For boys, 6 items and for girls,

10 items were scored as 0 for all subjects. The respective figure was 4 for children

aged 6–11 years and 2 for those aged 12–13 years; 4 for children with mild, 20 for

those with moderate, 52 for those with severe, and 62 for those with profound

intellectual disability; and 6 for children with no psychiatric disorder and 9 for

those with psychiatric disorder according to case files.

Table 2

Mean, standard deviation, maximum, median, and minimum scores for CBCL competence scales by

sex

n Mean SD Maximum Median Minimum

Activities

Raw score Males 49 3.2 2.3 8 3 0

Females 31 3 2 7 3 0

Total 80 3.2 2.2 8 3 0

T-score Males 49 34.1 9.7 55 33 20

Females 31 33.8 8.5 51 34 20

Total 80 34 9.2 55 33 20

Social

Raw score Males 50 3 1.8 8 3 0

Females 29 3.4 2.1 8 3 0

Total 79 3.2 19 8 3 0

T-score Males 50 31.1 7.9 54 30 20

Females 29 33.9 8.7 54 33 20

Total 79 32.1 8.3 54 30 20

School

Raw score Males 28 2.3 1.2 4 2.5 0

Females 18 2.6 1.1 5 2.3 1

Total 46 2.4 1.1 5 2.5 0

T-score Males 28 30.5 6.2 39 31 20

Females 18 29.7 5.4 45 29 23

Total 46 30.2 5.8 45 30 20

Total competence

Raw score Males 26 9.5 3.6 14.5 10 3

Females 16 10.4 3.7 18 10.5 3.5

Total 42 9.9 3.6 18 10.3 3

T-score Males 26 28.2 7 39 29 16

Females 16 30.8 7.5 47 31 17

Total 42 29.2 7.2 47 30 16


The number of items scored as 0 for more than 95% of children was 19. Eight

of these items were scored as 0 for more than 95% of the children in all subgroups

(boys and girls; children aged 6–11 years and those aged 12–13 years; children

with mild and those with moderate, severe, or profound intellectual disability; and

children with no psychiatric disorder and those with psychiatric disorder accord-

ing to case files). In addition to the two items mentioned in the previous

paragraph—‘Suicidal talks’ and ‘Alcohol, drugs’—the remaining six items were

‘Fears impulses’, ‘Hears things’, ‘Feels too guilty’, ‘Sets fires’, ‘Thinks about

sex’, and ‘Wishes to be opposite sex’.

In the total sample, the highest proportion of score 1 or 2 (94%) was for the

item ‘Acts too young’. The response to this item was 1 or 2 for more than 90% of

the children in all of the subgroups mentioned above.

Differences in item responses were statistically significant according to sex in

4 items, according to age in 1 item, according to level of intellectual disability in

16 items, and according to the presence of psychiatric disorder in 20 items

(Table 3).

Compared with the original CBCL normative samples (Achenbach, 1991), the

mean problem item scores for boys and girls aged 6–11 years were somewhat

different. Achenbach presents mean scores for non-referred boys and girls, and

referred boys and girls. The mean scores for about half of the items in the present

study were between these scores. The mean scores were lower than those of non-

referred children in 42 items for boys and in 47 items for girls, and higher than

those of referred children in 22 items for boys and in 19 items for girls. The items

with the lowest means compared with the normative samples were ‘Needs to be

perfect’ and ‘Self-conscious’, and those with the highest means compared with

the normative samples were ‘Acts too young’ and ‘Speech problem’.

3.3. Total Problem score and factor scores

The mean, maximum, median, and minimum scores and standard deviations

for Total Problem, Internalizing, and Externalizing scores are presented in Table 4.

The mean scores were not statistically different between girls and boys or children

aged 6–11 years and 12–13 years.

Total Problem, Internalizing, and Externalizing scores were highest among

children with moderate intellectual disability and lowest among those with

profound intellectual disability. Externalizing scores were significantly higher

among children with mild or moderate intellectual disability than among those

with severe or profound intellectual disability (Table 5). Total Problem and

Externalizing scores were significantly higher among children with psychiatric

disorder compared with those with no established psychiatric disorder (Table 6).

These differences were also significant among the subgroup of children with mild

intellectual disability, but among those with moderate, severe, or profound

intellectual disability, only the Externalizing score was significantly different.

Compared with the original CBCL normative samples (Achenbach, 1991),

Total Problem scores were significantly higher in the present study among boys


Table 3

Significant differences between the proportion of score 1 or 2 and score 0 according to sex, age, level

of intellectual disability, and presence of psychiatric disorder based on case files

Item Boys (b)

versus

girls (g)

Younger (y)

versus

older (o)

Mild (m)

versus moderate,

severe or

profound (s)

intellectual

disability

No psychological

disorder (n)

versus

psychological

disorder (p)

3 Argues a lot m > s***

6 BM outside toilet m < s***

7 Brags y < o*

8 Can’t concentrate n < p*

10 Can’t sit still n < p***

15 Cruel to animals m > s*

17 Daydreams n < p*

21 Destroys others’ things n < p*

25 Doesn’t get along n < p*

38 Is teased m > s**

42 Would rather be alone n < p**

43 Lying, cheating m > s*

45 Nervous n < p*

46 Nervous movements m < s**

48 Not liked n < p*

49 Constipated m < s**

50 Fearful, anxious n < p***

57 Attacks people b > g*

60 Plays with sex parts too much n < p*

64 Prefers younger kids m > s**

65 Refuses to talk b < g*

68 Screams a lot b > g* n < p*

71 Self-conscious m > s*

75 Shy m > s* n > p*

80 Stares blankly m < s**

83 Stores up unneeded things m > s*

84 Strange behavior n < p*

87 Moody n < p*

94 Teases a lot m > s* n < p**

95 Hot temper n < p*

97 Threatens people m > s* n < p*

104 Loud n < p**

106 Vandalism n < p*

107 Wets during day b < g* m < s***

108 Wets bed m < s**

112 Worries n < p*

Two-sided p values (Fisher’s exact test).* p < :05.** p < :01.*** p < :001.


Table 4

Mean, standard deviation, maximum, median, and minimum scores for Total Problem, Internalizing,

and Externalizing scales (n ¼ 90) by sex

Mean SD Maximum Median Minimum

Total Problem

Raw score Males 34.1 19.5 87 32 4

Females 33.8 17.4 71 37 5

Total 34 18.6 87 33 4

T-score Males 55.7 10.1 75 56 35

Females 56.6 9.3 71 60 37

Total 56.1 9.8 75 56.5 35

Internalizing

Raw score Males 4.9 4.3 17 4 0

Females 5.4 4.3 17 5 0

Total 5.1 4.3 17 4 0

T-score Males 48.3 9.9 70 49 32

Females 48.6 8.7 64 49 31

Total 48.4 9.4 70 49 31

Externalizing

Raw score Males 11.3 9 43 10 0

Females 9.7 7.9 29 10 0

Total 10.7 8.6 43 10 0

T-score Males 51.7 11.6 81 52 30

Females 51.6 12.3 72 54 32

Total 51.6 11.8 81 52 30

Table 5

Mean scores for Total Problem, Internalizing, and Externalizing scales (n ¼ 90) by level of

intellectual disability (ID)

Mild

(n ¼ 53)

Moderate

(n ¼ 17)

Severe

(n ¼ 11)

Profound

(n ¼ 9)

p valuea

Total Problem

Raw score 33.7 43.2 30.8 22.2 NSb

T-score 55.7 61 54.6 50.4 NSb

Internalizing

Raw score 4.9 6.9 4.2 3.6 NSb

T-score 47.9 53.3 45.4 45.9 NSb

Externalizing

Raw score 12 13.9 5.9 2.4 .001

T-score 53.5 56.9 47.3 38.9 <.001

a Unpaired t-tests: differences between children with mild or moderate ID and those with severe

or profound ID.b NS: not significant.


aged 6–11 years and among girls aged 6–11 or 12–13 years (single sample t-test).

Internalizing scores were lower and Externalizing scores higher in our study

among both girls and boys, but the differences were not statistically significant.

The trend of higher Externalizing scores among boys and higher Internalizing

scores among girls was consistent with the normative samples.

Among children with no psychiatric disorder, Total Problem, Internalizing,

and Externalizing scores did not statistically differ from those of the normative

samples. Among girls and boys aged 4–11 years and with psychiatric disorder

according to case files, Total Problem and Externalizing scores were significantly

higher than those of the normative samples, while Internalizing scores were not.

Correlation analyses were carried out between the CBCL (Total Problem,

Internalizing, and Externalizing scores) and the DBC (Total Behavior Problem

score and six subscale scores) as well as the ABS (Total Maladaptive, Social

Maladaptation, and Personal Maladaptation scores). Both the CBCL Total

Problem and Externalizing scores correlated highly with the DBC Total, the

DBC Disruptive, the ABS Total, and the ABS Social scores. These correlations

(p < :001) are displayed in Table 7, where correlations lower than .75 are

excluded.

3.4. Rated frequency of psychiatric disorders

With the T-score cut-off point of 60, the frequency of psychiatric disorder was

43%. The frequency was not statistically different by sex, age, or level of

intellectual disability. Of children with no psychiatric disorder according to case

files, 32% scored above the cut-off point, and the respective proportion was 67%

for those with psychiatric disorder according to case files (chi-square test:

p < :01).

Table 6

Mean scores for Total Problem, Internalizing, and Externalizing scales (n ¼ 90) by presence of

psychiatric disorder based on case files

Psychiatric disorder p value*

Absent (n ¼ 60) Present (n ¼ 30)

Total Problem

Raw score 29.4 43.1 .001

T-score 53.6 60.9 .001

Internalizing

Raw score 4.6 6 NS**

T-score 47.3 50.7 NS**

Externalizing

Raw score 8.6 14.9 .001

T-score 48.7 57.5 .001

* Unpaired t-tests.** NS: not significant.


4. Discussion

Our results show that the CBCL can be used to discriminate between children

with mild intellectual disability with and without emotional or psychiatric

disturbance. In assessing children with moderate, severe, or profound intellectual

disability, the CBCL may not be as reliable.

Item-by-item analysis of the problem items indicated that most items had a

discriminating capacity, yielding 0, 1, and 2 responses. However, the item ‘Acts

too young’, which was scored as 1 or 2 for most children, actually refers to

intellectual disability rather than behavioral disorder among these children. On

the other hand, suicidal talk and alcohol or drug abuse were not reported in this

sample, indicating that they are uncommon in this age group (6–13 years). Other

items seldom reported mostly concerned the child’s thoughts and feelings, which

are difficult to recognize if the child is nonverbal.

In only 17% of items, significant difference in the distribution of scores 0

versus 1 or 2 was observed according to the presence of psychiatric disorder based

on case files. The item ‘Shy or timid’ was interesting: a score of 1 or 2 was

significantly more common among children with no psychiatric disorder than

among those with a psychiatric disorder. Many of the CBCL items may not reflect

problem behavior of children with intellectual disability, indicating the need for

checklists designed specifically for this group.

The distributions of Total Problem, Internalizing, and Externalizing scores

were wide. Total Problem and Externalizing scores were higher among children

with psychiatric disorder than among those with no psychiatric disorder, but the

Table 7

Correlation coefficients of CBCL Total Problem and Externalizing scores versus both DBC Total

Behavior Problem and Disruptive scores as well as ABS Total Maladaptive Behavior and Social

Maladaptation scores

Total

sample

Mild

intellectual

disability

Moderate, severe,

or profound

intellectual disability

n r n r n r

CBCL versus DBC 80 45 35

CBCL Total versus DBC Total .82 .86 .83

CBCL Total versus DBC Disruptive .78 .77 .81

CBCL Ext. versus DBC Total .86 .77

CBCL Ext. versus DBC Disruptive .83 .85 .82

CBCL versus ABS 81 47 34

CBCL Total versus ABS Total .64 .65 .78

CBCL Total versus ABS Social .80

CBCL Ext. versus ABS Total .76 .76 .80

CBCL Ext. versus ABS Social .78 .76 .87

Correlation coefficients exceeding r ¼ :75 are included (simple linear regression, r: correlation

coefficient).


difference in the Internalizing score was not significant. An explanation for this

may be that internalizing symptoms of depression, for example, which often fail

to be recognized in children with normal intelligence, are even more likely to go

unrecognized in a nonverbal child.

The incomplete response to the competence section for the majority of children

is probably due to differences between children with normal intelligence and

those with intellectual disability in daily environment and activities: most

children and adolescents with intellectual disability in Finland attend special

schools with special educational schemes, and their possibilities for activities and

peer contacts outside school are limited. This situation may also partly explain the

low competence scores in the acceptable checklists, a finding consistent with that

of Bargagna et al. (2002).

Of the 30 children with psychiatric disorder, 20 scored above the CBCL cut-off

point, corresponding to a sensitivity of .667, and of the 60 children with no

psychiatric disorder according to case files, 41 scored below the cut-off point,

corresponding to a specificity of .683. Methodological differences in measure-

ments probably decrease these figures: assessment of psychiatric disorders in the

present study was based on all notes over the entire time period of the case files,

and previous medication and other interventions presumably also affect the

manifestation of a psychiatric disorder. Consequently, the child’s current problem

score may have fallen below the cut-off point of the checklist, which is intended to

measure disturbance only over the past six months. On the other hand, psychiatric

diagnoses based on case files may be underestimated because case files generally

include data on the child’s behavior only if behavior is the main concern at the

visit.

The rated frequency of psychiatric disorders among children with intellectual

disability, 43%, is similar to that of other recent studies based on checklists

(Cormack, Brown, & Hastings, 2000 (50%); Dekker et al., 2002 (50%); Einfeld &

Tonge, 1996 (41%); Linna et al., 1999 (32%)). In another study based mostly on

the same sample as the present study and assessed with the DBC, the rated

frequency of psychiatric disorders was 34% (Koskentausta & Almqvist, 2004).

Psychiatric disorders have frequently been reported to be more common

among intellectually disabled males than females (Gillberg, Persson, Grufman,

& Themner, 1986; Hardan & Sahl, 1997; Jacobson, 1990; Strømme & Diseth,

2000) and among children with severe intellectual disability (IQ < 50) than

among those with mild disability (Gillberg et al., 1986). However, Einfeld and

Tonge (1996) found no differences between the sexes, a result supported by our

study. Children with moderate intellectual disability were found to suffer most

from psychiatric disorders. This finding may be explained by the frequency of

psychiatric disorders actually increasing with decreasing IQ, and questionnaires

such as the CBCL fail to reveal all disorders among children with profound

intellectual disability.

While the population of the study area is fairly representative of the population

in Finland overall, it does not optimally represent the largest urban populations.

The study sample included virtually all children with intellectual disability of the


age cohort in the area, but the respondents comprised only about 60% of the

original sample. However, because the distribution of sex, age, level of intellec-

tual disability, and presence of psychiatric disorder according to case files was not

significantly different between respondents and non-respondents, the bias is

evidently small.

The CBCL had some limitations in its applicability for assessing children with

intellectual disability. The competence section of the CBCL does not accurately

describe daily life activities of children with moderate, severe, or profound

intellectual disability. Certain problem items do not measure the problem

behavior of children with intellectual disability sufficiently well, whereas pro-

blems typical of children with intellectual disability, such as motor and com-

munication limitations, are ignored in the checklist. The CBCL reveals

externalizing behavior of children with intellectual disability better than inter-

nalizing behavior, and the latter may be overlooked if assessment is based only on

the checklist. Similar to most checklists, the CBCL is more suited for children

with mild intellectual disability than for those with moderate, severe or profound

intellectual disability. Taking these limitations into account, the CBCL can be

recommended for use in the assessment of psychopathology among children and

adolescents with mild intellectual disability in Finland.

Acknowledgments

This study was supported by the Paajarvi Rehabilitation Center, Lammi,

Finland, the Research Foundation of Child Psychiatry, Finland, the Rinnekoti

Research Foundation, Espoo, Finland, and the Foundation of the Children’s

Castle, Helsinki, Finland.

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Documents

CBCL in the assessment of psychopathology in Finnish children with intellectual disability