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A Psychometric Analysis of the Child Behavior

Checklist DSM-Oriented Scales

Brad J. Nakamura & Chad Ebesutani & Adam Bernstein &

Bruce F. Chorpita

Published online: 9 December 2008# Springer Science + Business Media, LLC 2008

Abstract The Child Behavior Checklist for Ages 6 – 18

(CBCL/6-18) possesses newly developed DSM-OrientedScales, constructed through expert clinical judgment to

match selected categories for behavioral/emotional prob-

lems as described in the DSM-IV. The present investigation

examined the basic psychometric properties for all six

DSM-Oriented Scales (i.e., Affective, Anxiety, Somatic,

Attention-Deficit/Hyperactivity, Oppositional, and Conduct

Scales) in a large clinical sample of children and adoles-

cents ( N =673). Findings from the present study provide

strong evidence for the reliability, as well as convergent and

discriminative validity, of these scales. It appears that the

DSM-Oriented Scales may provide accurate supplementary

information that may be considered when formulating

clinical diagnoses.

Keywords Child behavior checklist . Diagnostic

and statistical manual . Psychometrics . Test validity.

Test reliability

The large research literature on psychological measurement

highlights the value of including multiple informants,

particularly parents, in youth assessment (Barbosa et al.

2002; Jensen et al. 1999; Manassis et al. 1997). The Child

Behavior Checklist (CBCL; Achenbach 1991; Achenbachand Rescorla 2001), the parent version of the Youth Self

Report (YSR; Achenbach 1991; Achenbach and Rescorla

2001), is among the most widely used parent-report

measures of youth symptoms, assessing a wide range of

problems. Beginning with its first edition (Achenbach and

Edelbrock 1983), the CBCL has provided empirically

derived Syndrome and Competence and Adaptive Scales,

as well as Internalizing, Externalizing, and Total Scales.

The extensive data behind the CBCL’s standardized scores

and clinical cutoffs have allowed for its use in a wide

variety of settings and have aided in current understandings

of youth psychopathology (e.g., Goodman and Scott 1999).

Within clinical settings, the CBCL has demonstrated

remarkable utility, particularly with respect to being able to

distinguish between referred and nonreferred populations

(Achenbach 1991; Chen et al. 1994; Drotar et al. 1995). For

example, a recent meta-analytic study found that scores

from the CBCL Internalizing Scale could discriminate

between youths with and without an anxiety disorder, as

well as youths with anxiety disorders and youths with

externalizing disorders (Seligman et al. 2004). Concerning

the more domain-specific CBCL Syndrome Scales, research

suggests significant and often clinically useful associations

with both broad-based (e.g., anxiety and affective disorders

groups) and specific (e.g., Attention Deficit Disorder and

Conduct Disorder) diagnostic groups (Edelbrock and

Costello 1988; Kasius et al. 1997; Kazdin and Heidish

1984; Eiraldi et al. 2000).

Although the CBCL Syndrome Scales have evidenced

several strengths, their empirical derivation via factor

analytic methods has yielded a long-recognized discordance

with nosology from the Diagnostic and Statistical Manual

of Mental Disorders (e.g., American Psychiatric Associa-

J Psychopathol Behav Assess (2009) 31:178 – 189

DOI 10.1007/s10862-008-9119-8

B. J. Nakamura (*)

Department of Psychology, University of Hawai‘i at Mā noa,

2430 Campus Road,

Honolulu, HI 96822, USA

e-mail: [email protected]

C. Ebesutani : A. Bernstein : B. F. Chorpita

University of California,

Los Angeles, CA, USA

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tion 2000).1 This discordance has been supported by

several studies that suggest that the CBCL Syndrome

Scales yield only modest associations with DSM-IV

disorders, have limited positive predictive values, and

seemingly do not map well onto specific diagnoses

(Brunshaw and Szatmari 1988; Jensen et al. 1993; Kasius

et al. 1997). This lack of concordance may be of concern

given that the DSM-IV classification system forms the basisfor most psychopathology research and treatment protocols,

and that mental health services reimbursement eligibility in

America is largely tied to DSM-IV diagnoses (Achenbach

and Dumenci 2001; Doucette 2002).

In an effort to provide closer linkage with prevailing

DSM nosology, Achenbach et al. (2003) developed the

CBCL DSM-Oriented Scales to supplement the CBCL

Syndrome Scales. Whereas the Syndrome Scales were

derived empirically via factor analytic methods, DSM-

Oriented Scales were constructed through agreement in

experts’ ratings of the preexisting items’ consistency with

DSM-IV diagnostic criteria. Due to their recent construc-tion, research on the CBCL DSM-Oriented scales is

limited. Among the investigations conducted to date,

Achenbach et al. (2003) reported that the psychometric

properties of the DSM-Oriented Scales were generally

similar to those of the Syndrome Scales when comparing

among the same large national sample of referred and non-

referred children. For instance, internal consistency and

test-retest reliability for these scales were found to be good,

with Cronbach Alphas ranging from .75 to .84 and test-

retest coefficients ranging from .78 to .88.

Other research, however, has provided mixed results,

warranting further investigations. For instance, van Lang et

al. (2005) examined the CBCL’s child-report counterpart,

the YSR, and found that a measure of Major Depressive

Disorder (MDD) corresponded more closely with the YSR

DSM-Oriented Affective Problems Scale than with either

the YSR Anxious/Depressed or Withdrawn/Depressed

Syndrome Scale. However, these investigators also found

that measures of Generalized Anxiety Disorder (GAD) and

Separation Anxiety Disorder (SAD) corresponded more

closely with the YSR Anxious/Depressed Syndrome Scale

than with the YSR DSM-Oriented Anxiety Problems Scale.

Vreugdenhil et al. (2006) also found low concordance

between the YSR DSM-Oriented scales and DSM-IV

DISC-C diagnoses among incarcerated adolescents. Kendall

et al.( 2007) also argued that the CBCL DSM-Oriented

Anxiety Scale could be improved upon due to some

problematic features (e.g., only six items collectively

represent GAD, SAD and Simple Phobia and an absence

of somatic-related items). Accordingly, Kendall et al. (2007)

constructed a modified CBCL-based DSM-Oriented Anxiety

scale with 10 additional items. These authors found that the

modifications led to an increased ability for mothers’ reports

(but not fathers’ reports) to predict anxiety disorder status

among adolescent youths when compared with the CBCL’s

official DSM-Oriented Anxiety Scale, the Internalizing TotalScale, and the Anxious/Depressed Syndrome Scale.

In summary, although the CBCL DSM-Oriented Scales

have been criticized for not mapping strongly to certain

DSM diagnoses, these scales have nonetheless received

some support in initial investigations (e.g., Achenbach et al.

2003). Additionally, their congruence with DSM nosology

offers the potential for specific categorical applications that

may not be possible with the Syndrome scales. However, the

strengths and weaknesses of their psychometric properties

are not yet well substantiated in large clinical samples. It is

thus useful to further investigate all CBCL DSM-Oriented

Scales for future clinical applications.The present study evaluated numerous psychometric

properties of all six DSM-Oriented Scales in a large, clinic-

referred sample of youth. Four hypotheses were examined.

First, it was predicted that each DSM-Oriented Scale would

evidence an acceptable level of reliability as demonstrated

through internal consistency analyses. Second, concerning

convergent validity, each DSM-Oriented Scale was

expected to demonstrate convergence (i.e., significant

positive correlations) with all available construct-consistent

instrument scales. Third, with respect to divergent validity,

each DSM-Oriented Scale was expected to demonstrate

divergence (i.e., lack of a significant correlation) with

construct-inconsistent instrument scales. Fourth, concerning

the DSM-Oriented Scales’ discriminative properties, it was

predicted that these scale scores would significantly

discriminate between youths with and without the mental

health diagnosis relevant to each DSM-Oriented Scale.

Method

Participants

The present investigation was conducted across a clinical

sample of youths, whose caregivers completed either the

CBCL/4-18 or CBCL/6-18. Participants were selected on

the basis of the availability of completed CBCL/4-18 (n=

555) and CBCL/6-18 (n =118) data from 813 consecutive

referrals made to the Center for Cognitive Behavioral

Therapy (CCBT), at the University of Hawai‘i at Mā noa,

for a mental health assessment. The CCBT utilized the

CBCL/4-18 for all intake assessments up until approxi-

mately May 2003 and switched to the use of the CBCL/6-

1 It is important to note that no “gold standard” exists for determining

diagnoses. Moreover, the question of whether the described disorders

are in fact categorical (as in the DSM) or dimensional (as measured by

CBCL scale scores) is one of active debate (e.g., Haslam, 2003).

J Psychopathol Behav Assess (2009) 31:178 – 189 179179

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18 shortly thereafter. This form changeover occurred after

the authors became aware of the new CBCL/6-18 form.

Participants were excluded from analyses if they were

missing more than (a) eight items on their entire CBCL, (b)

two items from their DSM-Oriented Attention-Deficit/

Hyperactivity Problems Scale (CBCL/4-18 youths would

have at least two of their five items missing due to version

differences explained below) or (c) 20% of their item-responses necessary for calculating any other DSM-Oriented

scale. These rationally-derived rules for listwise deletion

allowed for maximum use of available data without

excessive reliance on mean-substitution procedures (see

Procedure below) and are more stringent than missing

item-level data rules in previous CBCL studies (cf. Galera

et al. 2005). The mean age of the final combined sample ( N =

673) of youths was 12.3 years (SD=3.2; range=4.2 to 19.7),

and the group consisted of 454 boys (67.5%) and 216 girls

(32.1%; gender data were missing for three participants).

A wide range of ethnicities and DSM-IV (1994)

diagnoses were represented in the present sample (seeTable 1). Notably, 120 participants did not receive a

diagnosis. However, the absence of a diagnosis does not

indicate that these youths did not have mental health

concerns or that meaningful recommendations were not

provided following the assessment. Additionally, while the

sample includes more youths with principal diagnoses of an

externalizing (e.g., Disruptive Behavior and Attention/

Hyperactivity) than internalizing (e.g., Anxiety and De-

pression) nature, the proportion of internalizing-type diag-

noses exceeds that typically found in youth disorder

prevalence studies (e.g., Garland et al. 2001). Many of the

assessment instruments utilized in the study (see Measures below) thus examine internalizing symptoms.

Numerous analytic strategies were applied to investigate

whether there were significant differences between CBCL/

4-18 and CBCL/6-18 youths. One, eight, and seven

separate chi-square tests, respectively, examined the rela-

tionships between CBCL version (CBCL/4-18 and CBCL/

6-18) and (a) gender, (b) principal diagnosis, and (c) parent-

reported child ethnicity (based on major categories in

Table 1). Additionally, a one-way ANOVA was conducted

to determine if there were significant age differences

between CBCL/4-18 and CBCL/6-18 participants. All

analyses were performed using a 99.7% confidence interval(alpha of .003 after a Bonferroni correction for the 17 tests

above performed using a 95% confidence interval). Only

one of these 17 tests emerged significant. Concerning

principal diagnosis, a one-sample chi-square test for

Table 1 Demographic

information for all study

participants

Youths with co-principal

diagnoses are included in totals

for each of their principal

diagnoses

CBCL/4-18 CBCL/6-18 Combined

n=555 n=118 N =673

Age:

Minimum 4.2 5.8 4.2

Maximum 19.7 18.0 19.7

Mean (SD) 12.3 (3.1) 12.6 (3.5) 12.3 (3.2)

Gender

Boy 375 79 454

Girl 179 37 216

Missing 1 2 3

Ethnicity

Multiethnic 276 46 322

Asian 85 12 97

White 85 10 95

Pacific Islander 37 7 44

African American 9 2 11

Latino / Hispanic 7 1 8

Native American 0 0 0

Other 45 2 47Missing 11 38 49

Principal diagnoses

Disruptive behavior 152 50 202

Attention/hyperactivity 124 16 140

Anxiety 112 18 130

Depressive 25 4 29

Adjustment 20 4 24

Substance 7 3 10

Other 56 9 65

None 98 22 120

180 J Psychopathol Behav Assess (2009) 31:178 – 189

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assessing the relationship between CBCL version (CBCL/

4-18 versus CBCL/6-18) and whether or not a youth had a

“Disruptive Behavior Diagnoses” was found significant, χ2

(1, N =673)=10.4 p=.001, suggesting a greater proportion

of “Disruptive Behavior Diagnoses” associated with the

CBCL/6-18. All other tests were non-significant, suggest-

ing no other systematic differences between the study’s two

sub-samples.Primary caregivers consisted of 525 biological mothers

(78.0%), 70 biological fathers (10.4%), 24 grandmothers

(3.6%), 17 other caregivers (2.5%), 16 foster mothers

(2.4%), 12 stepfathers (1.8%), 7 grandfathers (1.0%), and

2 stepmothers (0.3%). Marital status among primary care-

givers was 306 married (45.5%), 191 divorced or separated

(28.4%), 104 single (15.5%), and 19 widowed (2.8%)

(marital status data were missing for 53 caregivers).

Measures

Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent Versions (ADIS-IV-C/P; Silverman and Albano

1996 ) The ADIS-IV-C/P is a semi-structured clinical

interview for parents and children ages 7 to 17 that is

specifically designed for DSM-IV diagnoses of childhood

anxiety, mood, and behavioral disorders. Assessment

involves two interviews, one with the caregiver(s) and one

with the child. The ADIS-IV-C/P is a revision of the

Anxiety Disorders Interview Schedule for Children (Silverman

1991), which has demonstrated satisfactory reliability across a

range of ages and other parameters (Silverman and Eisen

1992). In the present study, interviews were conducted by Ph.

D.-level clinical child psychologists and senior doctoral

students in clinical psychology who had been trained to

reliability using the ADIS-IV-C/P. Training first involved

observation of three interviews conducted by trained inter-

viewers. The trainee then conducted a series of five inter-

views while being observed by a criterion-trained interviewer.

An interviewer is considered trained after he/she matches the

experienced interviewer on all clinical diagnoses in three of

the five interviews. In a subset of 16 randomly selected

families in this sample, interrater agreement for principal

diagnoses between trainees who administered the ADIS-IV-

C/P and trainers who observed the administration was found

to be excellent (kappa=.77).

Affect and Arousal Scale (AFARS; Chorpita et al. 2000a;

Daleiden et al. 2000 ) The AFARS is a 27-item self-report

questionnaire designed to measure (Cronbach’s alpha

coefficients for present sample): positive affect (PA; .83),

negative affect (NA; .81), and physiological hyperarousal

(PH; .86) in children and adolescents. The AFARS requires

respondents to rate how true each item is with respect to

their usual feelings. Items are scored on a 4-point scale

ranging from 0 (never true) to 3 (always true). Internal

consistency and favorable validity have been demonstrated

for the AFARS’ three scales (Chorpita et al. 2000a;

Daleiden et al. 2000).

Child Behavior Checklist for Ages 6 – 18 (CBCL/6-18;

Achenbach and Rescorla 2001 ) The 113 items on this

measure are rated as Not True (0), Somewhat or SometimesTrue (1), or Very True or Often True (2). Validity and

reliability are excellent, and extensive normative data are

available for children ranging from 6 to 18. The CBCL/6-

18 is a slightly modified revision of the Child Behavior

Checklist for Ages 4 – 18 (CBCL/4-18; Achenbach 1991).

Changes from the CBCL/4-18 to the CBCL/6-18 include

new age norms, the replacement of ineffective items (i.e.,

items 2, 4, 5, 28, 78, 99), and the creation of six DSM-

Oriented Scales. The six DSM-Oriented Scales include: (a)

Affective Problems (Dysthymic and Major Depressive

Disorders), (b) Anxiety Problems [Generalized Anxiety

Disorder (GAD), Separation Anxiety Disorder (SAD), andSpecific Phobia (SPEC)], (c) Attention/Deficit/Hyperactivity

Problems (Hyperactive-Impulsive and Inattentive subtypes),

(d) Conduct Problems [Conduct Disorder (CD)], (e) Oppo-

sitional Defiant Problems [Oppositional Defiant Disorder

(ODD)], and (f) Somatic Problems (Somatization and

Somatoform Disorders).

Children’ s Depression Inventory (CDI; Kovacs 1981 ) The

CDI is a 27-item self-report measure designed to assess

cognitive, behavioral, and affective symptoms of depres-

sion. Each item is scored from 0 to 2, and the sum of all

item scores yields the total CDI score, which ranges from 0

to 54, with higher scores indicating more depressive

symptoms. The CDI has extensive support for its reliability

and validity (e.g., Saylor et al. 1984).

Dimensional Ratings (Chorpita et al. 2000b ) Dimensional

Ratings, also known as Clinical Severity Ratings, are

clinician-reported ratings based on the interference rating

scale (i.e., a functional impairment rating scale) developed

previously for the ADIS-C/P (Silverman and Nelles 1988).

Dimensional Ratings range from 0 to 8 and are provided for

each ADIS-IV-C/P diagnostic area on the basis of informa-

tion obtained during each the child and parent interview.

Larger numbers reflect greater stress and impairment, but

not necessarily the presence or absence of a diagnosis (e.g.,

it is possible to get a high Conduct Disorder dimensional

rating without receiving this diagnosis because other

diagnostic symptom criteria were not met). The presence

of a diagnosis, however, meant that the associated Dimen-

sional Rating was at least a “4,” indicating clinically

significant impairment in that area. Each child in the

present investigation was assigned two different ratings


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for each diagnostic area, one based on the child report

alone, and one based on the parent report alone. Dimen-

sional ratings have been found to demonstrate good to

excellent interrater reliability and convergent validity (Gray

et al. 2001). The dimensional ratings relevant to the current

study included: (a) Child and Parent (Mean) Anxiety,

comprised of constituent Separation Anxiety, Social Anx-

iety, Specific Phobia, Generalized Anxiety, Panic, Agora- phobia, Obsessions/Compulsions, and Posttraumatic Stress

ratings, (b) Parent Oppositional, and (c) Parent Conduct

dimensional ratings.

Revised Child Anxiety and Depression Scales (RCADS;

Chorpita et al. 2000c ) The RCADS is a 47-item revision of

the Spence Children’s Anxiety Scale (SCAS; Spence 1998).

Children rate the extent to which each item is true of them

on a 0 to 3 scale, corresponding to the anchors of “never,”

“sometimes,” “often,” and “always.” Factor analytic inves-

tigations suggest the following six subscales (Cronbach’s

alpha coefficients for present sample): Separation AnxietyDisorder (SAD; .80), Social Phobia (SOC; .85), General-

ized Anxiety Disorder (GAD; .83), Obsessive-Compulsive

Disorder (OCD; .81), Panic Disorder (PD; .85), and Major

Depressive Disorder (MDD; .84). These subscales have

demonstrated good factorial validity, internal consistency,

one-week test-retest reliability, and convergent and discrim-

inant validity (Chorpita, et al. 2000c).

Revised Children’ s Manifest Anxiety Scale (RCMAS; Reynolds

and Richmond 1978 ) The RCMAS is as 37-item self-report

measure designed to assess the presence of cognitive,

behavioral, or affective symptoms of anxiety and negative

affect. Of the 37 items in total, 28 dichotomous (i.e., yes/

no) items are summed to yield an Anxiety Scale score,

ranging from 0 to 28, with higher scores representing

greater anxiety. The other 9 items are summed to assess

social desirability (i.e., “Lie scale”). Its constituent scales

include (Cronbach’s alpha coefficients for present sample):

Anxiety (.90), Worry/Oversensitivity (.86), Physiological

(.69), Social Concerns/Concentration (.72), and Lie (.75)

components. This instrument has been one of the most

widely used instruments for assessing childhood anxiety,

and has been demonstrated to be reliable across different

gender, racial, and age groups in children from age 7 to 17

(Reynolds and Paget 1983).

Procedure

All participants and their legal guardian(s) underwent

standardized Institutional Review Board-approved notice

of privacy and consent procedures prior to any data

collection. All data were gathered and entered into a central

database through the established operating procedures of

the CCBT clinic, and subsequently extracted electronically

from the system for analyses.

Item-level changes between the CBCL/4-18 and CBCL

6-18 did not affect score-calculations for the DSM-Oriented

Anxiety Problems Scale (items 11, 29, 30, 45, 50, 112),

Somatic Problems Scale (items 56a, 56b, 56c, 56d, 56e,

56f, 56g), or Oppositional Problems Scale (items 3, 22, 23,86, 95) because the items comprising these scales were

identical across CBCL forms. Item-level changes did,

however, affect (a) one item (item 5) on the DSM-Oriented

Affective Problems Scale (items 5, 14, 18, 24, 35, 52, 54,

76, 77, 91, 100, 102, 103), (b) two items (items 4, 78) on

the DSM-Oriented Attention-Deficit/Hyperactivity Prob-

lems Scale (items 4, 8, 10, 41, 78, 93, 104), and (c) one

item (item 28) on the DSM-Oriented Conduct Problems

Scale (items 15, 16, 21, 26, 28, 37, 39, 43, 57, 67, 72, 81,

82, 90, 97, 101, 106). Achenbach’s ASEBA (2001) manual

recommends using raw scores when conducting analyses on

the narrow-band Syndrome scales in order to account for the full range of variation in these scales. Consistent with

this recommendation, all analyses in the present investiga-

tion were conducted on DSM-Oriented raw scale scores.

DSM-Oriented Scale scores unaffected by item-level

changes (Anxiety, Somatic, and Oppositional) between the

CBCL/4-18 and CBCL/6-18 versions were calculated by

summing all relevant items within the scale. Consistent

with Achenbach’s (2001) recommendations, DSM-Oriented

Scale scores affected by version differences (Affective,

Attention-Deficit/Hyperactivity, and Conduct) were calcu-

lated by treating changed problem items as missing.

Specifically, these scale scores were calculated by summing

the remaining items and multiplying that score by the total

number of items divided by the total number of items minus

the number of missing items. Following listwise deletion

logic above (see "Participants"), scale scores for other

measures were excluded from analyses in a pairwise

fashion if more than 20% of the item-responses comprising

the scale were missing, with missing items handled with the

same procedure described immediately above.

Analytic Strategy

To test the first hypothesis, Cronbach’s alpha coefficients

were calculated for each DSM-Oriented Scale. Hypothesis

two was evaluated by calculating zero-order bivariate

correlations between each DSM-Oriented Scale and several

construct-consistent instruments scales. See bolded text in

Tables 3 and 4 for all a priori hypothesized DSM-Oriented

Scale by measure convergent (i.e., significant and positive)

correlations. Towards the goal of evaluating divergent

validity, the third hypothesis involved calculating zero-

order bivariate correlations between each scale and several


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construct-inconsistent instrument scales. See italicized text

in Tables 3 and 4 for all a priori hypothesized DSM-

Oriented Scale by measure divergent (i.e., non-significant)

correlations (cf. Chorpita et al. 2005). Note that Child

Oppositional and Delinquent Dimensional Ratings are not

obtained during ADIS-IV-C/P administration and, there-

fore, were not available for analysis. When a significant and

positive relationship unexpectedly did emerge, Fisher ’s z -tests (Meng et al. 1992) were calculated to determine if the

DSM-Oriented Scale under examination was correlated

significantly more with construct-consistent validity indices

than with the construct-inconsistent scale.

In order to evaluate each scales’ discriminative proper-

ties, the fourth hypothesis involved performing one-way

ANOVAs to evaluate the relationship between the presence

or absence of various DSM-IV (1994) diagnoses (anywhere

in a child’s diagnostic profile; e.g., primary, secondary, or

tertiary, etc.) and relevant DSM-Oriented Scale scores.

Capitalizing on the diagnostic breadth afforded by this

sample, the over-arching strategy within each DSM-Oriented Scale by diagnosis analysis first involved using

an ANOVA to detect significant differences between three

groups of children: (a) youths with a specific disorder under

examination, (b) youths with a disorder from the same

diagnostic category as the specific disorder under exami-

nation, but without that specific disorder under examina-

tion, and (c) youths that did not have the specific disorder

under examination or any disorder in that same diagnostic

category. For example, concerning the DSM-Oriented

Affective Problems Scale, it was hypothesized that an

ANOVA would detect differences between (a) youths with

Dysthymic Disorder (DD), (b) youths without DD but with

another type depressive disorder [i.e., any type of Major

Depressive Disorder (MDD) or Depressive Disorder Not

Otherwise Specified], and (c) and youths with no depres-

sive disorder. See Table 5 for all a priori hypothesized

DSM-Oriented Scale by disorder analyses.

The strength of the initial ANOVA was assessed by η2,

with .01, .06, and .14 and interpreted as small, medium, and

large effect sizes, respectively (Green and Salkind 2005). In

performing follow-up tests to evaluate pairwise mean

differences among the three types of groups above, Tukey’s

HSD tests were used when Levene’s test of equality of error

variances was found non-significant. If equal variances

could not be assumed, Dunnett ’s C test was utilized for post

hoc comparisons. Given the preliminary nature of the

literature on the DSM-Oriented Scales’ diagnostic discrim-

inative properties, youths with the specific disorder under examination were hypothesized to score higher than youths

with no related diagnosis, but not necessarily higher than

youths with a disorder from the same category. In order to

control the experiment-wise error rate, all analyses were

performed using a moderately conservative 99% confidence

interval (alpha level of .01).

Results

Reliability

Cronbach’s alpha coefficients are presented in Table 2. All

reliability coefficients were favorable, ranging from .71

(Somatic Problems items) to .89 (Conduct Problems items)

in the present sample.

Convergent Validity

As predicted, the DSM-Oriented Affective Problems Scale

correlated significantly and positively with all convergent

validity criterion measures (see Table 3 for these results).

The DSM-Oriented Anxiety Problems Scale also correlated

significantly and positively with all but one (i.e., RCMAS

Total Anxiety Scale) of its convergent validity criterion

measures. The DSM-Oriented Somatic Problems Scale

correlated significantly and positively with the AFARS-

PH Scale, but did not significantly correlate with the

RCMAS Physiological Scale. Correlations of the CBCL

DSM-Oriented Attention-Deficit/Hyperactivity, Opposi-

tional, and Conduct Problems scales with convergent

validity criterion measures are displayed in Table 4. As

Table 2 Alpha coefficients for CBCL/4-18 and CBCL/6-18 DSM-oriented scale scores

CBCL/4-18 sample CBCL 6-18 sample Combined sample

Scale Number of items n Alpha n Alpha n Alpha

Conduct problemsa 17 – – 109 .89 – –

ADHD problemsa 7 – – 116 .85 – –

Oppositional problems 5 542 .79 116 .86 658 .81

Affective problemsa 13 – – 110 .81 – –

Anxiety problems 6 533 .77 116 .79 649 .77

Somatic problems 7 537 .77 115 .71 652 .76

a As these scales contained new items on the CBCL/6-18, alpha coefficients for these scales could not be computed for those youths with a CBCL/4-18


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predicted, all three of these DSM-Oriented Scales signifi-

cantly and positively correlated with their respective

convergent validity criterion measures.

Divergent Validity

DSM-Oriented Affective, Anxiety, and Somatic Problems

scales Contrary to expectation, the DSM-Oriented Affec-

tive Problems Scale correlated significantly and positively

with Parent Oppositional and Delinquent Dimensional

Ratings (see Table 4). For comparative purposes, two sets

of pairwise follow-up Fisher ’s z -tests (Meng et al. 1992)

compared these two unexpected correlations against the

correlations between the DSM-Oriented Affective Problems

Scale and its four convergent validity indices (see bolded

text in Table 3). Concerning the first set of four pairwise

follow-up tests (i.e., the correlation between the DSM-

Oriented Affective Problems Scale and the Parent Opposi-

tional Dimensional Rating versus the correlation between

the DSM-Oriented Affective Problems Scale and (a) the

Parent Depression Dimensional Rating, (b) Child Depres-

sion Dimensional Rating, (c) RCADS MDD Scale, and (d)

CDI Total Scale), the DSM-Oriented Affective Problems

Scale was found to be significantly more correlated with the

Parent Depression Dimensional Rating than with the Parent

Oppositional Dimensional Rating, z (579)=4.88, p< .001.

No other correlations, however, were significantly different.

Regarding the second set of four pairwise follow-up tests

(i.e., the correlation between the DSM-Oriented Affective

Problems Scale and the Parent Delinquent Dimensional

Rating versus the correlation between the DSM-Oriented

Affective Problems Scale and the same four convergent

indices above), the DSM-Oriented Affective Problems Scale

was found to be significantly more correlated with (a) the

Parent Depression Dimensional Rating, z (540)=7.49,

p<.001, (b) the Child Depression Dimensional Rating, z

( 518)=4.64, p< .001, (c) the RCADS MDD Scale, z (508)=

3.11, p=.002, and (d) the CDI Total Scale, z (326)=3.19,

p=.001, than with the Parent Delinquent Dimensional

Rating. Both ANOVA analyses for DD, F (2, 670)= 37.9,

p<.001, η2=.10, and MDD, F (2, 670)=42.1, p<.001,

η2=.11, were significant. Follow-up tests evaluating pairwise

differences supported the fourth hypothesis and pointed to

higher scores for youths with DD and MDD over youths

with no depressive disorders (see Table 5 for means, standard

deviations, and all pairwise comparison results).

Results concerning the DSM-Oriented Anxiety Problems

Scale were mostly supported (see Table 4). There were no

significant relationships between this scale and one of two

divergent validity criteria. Unexpectedly, this scale signif-

icantly and positively related to the Parent Oppositional

Dimensional Rating (see Table 4). Follow-up Fisher ’s z -

tests (Meng et al. 1992) revealed that the DSM-Oriented

Anxiety Problems Scale was significantly more correlated

with only one of its four convergent indices (see bolded text

in Table 3). Specifically, the DSM-Oriented Anxiety

Problems Scale was significantly more correlated with the

Parent Anxiety (Mean) Dimensional Rating, z (536)=8.92,

p< .001, than with the Parent Oppositional Dimensional

Rating. Concerning the fourth hypothesis, all overall DSM-

Oriented Anxiety Scale ANOVAs were found significant:

(a) SAD, F (2, 670)= 59.0, p< .001, η2=.15, (b) Panic

Disorder (any type) or Agoraphobia without a History of

Panic (PDA), F (2, 670)=59.7, p<.001, η2=.15, (c) SOC,

Table 3 Correlation matrix for child behavior checklist DSM-oriented scales and selected internalizing measures

DSM-oriented scales

Affect Anxiety Somatic ADHD ODD CD

Depression measures

Parent depression dimensional rating (n=542) .54** .30** .28** .02 .17** .19**

Child depression dimensional rating (n=525) .41** .17** .20** −.01 .07 .10

RCADS, depression scale (n=619) .33** .16** .25** .07 .09−

.01

Children’s depression inventory, total scale (n=423) .34** .09 .17** .07 .12* .11

Anxiety measures

Parent anxiety (mean) dimensional rating (n=536) .42** .59** .32** .05 .13* .23*

Child anxiety (mean) dimensional rating (n=518) .26** .27** .23** −.01 −.07 −.02

RCADS, total anxiety scale (n = 610) .20** .18** .22** .10 .01 −.05

RCMAS, total Scale (n = 167) .16 .05 .16 −.08 −.08 −.16

Arousal measures

AFARS, physiological hyperarousal scale (n=578) .15** .09 .15** .11* .12* .06

RCMAS, physiological scale (n = 167) .17 .05 .16 .03 .03 −.08

Bold print highlights convergent indices. Italicized print highlights divergent indices

AFARS = Affect and Arousal Scale for Children, RCADS = Revised Children’s Anxiety and Depression Scales, RCMAS = Revised Children’s

Manifest Anxiety Scale

* p<0.01; ** p<0.001


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F (2, 670)=57.7, p <.001, η2=.15, (d) SPEC, F (2, 670)=

59.3, p<.001, η2=.15, (e) OCD, F (2, 670)= 62.8, p< .001,

η2=.16, (f) GAD, F (2, 670)=58.8, p< .001, η2=.15, and (g)

Posttraumatic Stress Disorder (PTSD), F (2, 670=57.7, p <.001, η

2=.15. As seen in Table 5, all subsequent

pairwise test results supported the fourth hypothesis and

indicated that youths with the specific disorder under

examination had significantly higher scores than youths

with no anxiety disorder.

Predictions on the divergent validity relationships be-

tween the DSM-Oriented Somatic Problems Scale were

uniformly supported (see Table 4). Regarding the fourth

hypothesis, all overall ANOVAs were significant: (a) MDD,

F (2, 670)=28.8 p< .001, η2=.08, (b) PDA, F (2, 670)=28.1,

p <.001, η2=.08, and (c) SAD, F (2, 670)= 30.8, p<.001,

η2=.08. Follow-up pairwise results partially supported

predictions (see Table 5) in that youths with MDD and

PDA scored higher than youths without other somatically

associated diagnoses. However, youths with SAD did not

score higher than youths without other somatically associ-

ated diagnoses.

DSM-Oriented Attention-Deficit/Hyperactivity, Oppositional,

and Conduct Problems scales As displayed in Table 3,

pre dic tions for the DSM -Oriented Atten tion-Defic it/

Hyperactivity Problems Scale were supported, and this scale

did not correlate significantly with any anxiety or depression

scale scores. The overall ANOVA examining mean differ-

ences between youths with Attention-Deficit/Hyperactivity

Disorder, Combined Type (ADHD-C), Attention-Deficit/

Hyperactivity Disorder, Primarily Hyperactive/Impulsive

Type (ADHD-PH), Attention-Deficit/Hyperactivity Disorder,

Primarily Inattentive Type (ADHD-PI), and youths without

ADHD was found significant, F (3, 669)=35.5, p<.001,

η2=.14. The fourth hypothesis was supported and youths

with any type of ADHD scored significantly higher on this

scale than youths without this disorder.

Divergent validity correlation results for the DSM-

Oriented Oppositional Problems Scale are displayed in

Table 3. Predictions were somewhat supported and no

significant relationship emerged for five of eight examinedrelationships. For the three unexpected findings, three sets

of follow-up Fisher ’s z -tests (Meng et al. 1992) compared

the three unexpected correlations against the correlation

between the DSM-Oriented Oppositional Problems Scale

and its convergent validity index (i.e., the Parent Opposi-

tional Dimensional Rating). These follow-up analyses

revealed that the DSM-Oriented Oppositional Problems

Scale was significantly more correlated with the Parent

Oppositional Dimensional rating than with the (a) Parent

Depression Dimensional Rating, z (541)=10.7, p <.001, (b)

Parent Anxiety (Mean) Dimensional Rating, z (536)=11.6,

p < .001, and (c) CDI Total Scale score z (327)=9.11,

p< .001. One-way ANOVA results, F (2, 670)= 87.2, p<

.001, η2=.21, were consistent with the fourth hypothesis

and children with ODD also evidenced higher DSM-

Oriented Oppositional Problems Scale scores than youths

without a disruptive behavior disorder.

Divergent validity results for the DSM-Oriented Conduct

Problems scale almost mirrored those demonstrated by the

DSM-Oriented Oppositional Problems scale (see Table 3).

Specifically, the DSM-Oriented Conduct Problems scale

demonstrated no significant correlations for six of eight

examined pairwise relationships. However, follow-up hy-

potheses were again supported and Fisher ’s z -tests (Meng et

al. 1992) revealed that this DSM-Oriented Scale was

significantly more correlated with the Parent Delinquent

Dimensional rating than with the (a) Parent Depression

Dimensional Rating, z (540)=9.74, p<.001 and (b) Parent

Anxiety (Mean) Dimensional Rating, z (535)=10.3, p<.001.

One-way ANOVA results were hypothesis-consistent,

F (2, 670)= 172.7, p<.001, η2=.34, and children with CD

evidenced higher DSM-Oriented Conduct Problems scale

scores than youths without a disruptive behavior disorder.

Table 4 Correlation matrix for child behavior checklist DSM-oriented scales and selected externalizing measures

DSM-oriented scales

Affect Anxiety Somatic ADHD ODD CD

Inattention/hyperactivity measures

Parent inattention dimensional rating (n=545) .12* .05 .04 .56** .34** .27**

Child inattention dimensional rating (n=528) .09 .05 .02 .23** .13* .14**

Parent hyperactivity dimensional rating (n=545) .08 .09 .03 .62** .38** .34**

Child hyperactivity dimensional rating (n=529) .05 .05 .00 .31** .20** .20**

Disruptive behavior measures

Parent oppositional dimensional rating (n=547) .31** .16** .08 .43** .67** .64**

Parent delinquent dimensional rating (n=544) .16** −.03 −.09 .21** .37** .65**

Bold print highlights convergent indices. Italicized print highlights divergent indices

* p<0.01; ** p<0.001


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Table 5 DSM-oriented means

and (standard deviations) for

children with and without se-

lected diagnoses anywhere in

their diagnostic profile1

DBD NOS = Disruptive

Behavior Disorder Not Other-

wise Specified, DEP NOS =

Depressive Disorder Not

Otherwise Specified, Panic

Disorder = Panic Disorder with

or without Agoraphobia. Giventhe absence of youths with

Somatization and Somatoform

Disorders in the current clinical

sample and Chorpita et al.,’s

(2000c) findings on somatic

arousal in selected internalizing

disorders, analyses for the

Somatic Problems scale above

examined youths with Major

Depressive Disorder, Panic

Disorder and/or Separation

Anxiety Disorder 1 All diagnoses, whether princi-

pal or non-principal, for which

children met full DSM-criteriawere included in their diagnostic

profilesabc Differing letter superscripts

indicate a significant pairwise

mean differences at 99%

confidence interval

DSM-oriented scale by disorder analyses n Mean (SD)

Affective problems

Dysthymic disorder 10 9.1 (5.9) a

Major depressive or DEP NOS disorder without dysthymic disorder 37 10.5 (5.2) a

No dysthymic, major depressive, or DEP NOS disorder 626 4.8 (4.1) b

Major depressive disorder 34 11.3 (5.4) a

Dysthymic or DEP NOS disorder without major depressive disorder 13 7.4 (3.8) b

No dysthymic, major depressive, or DEP NOS disorder 626 4.8 (4.1) b

Anxiety problems

Separation anxiety disorder 34 5.6 (3.3) a

Anxiety disorder without separation anxiety disorder 169 4.8 (3.1) a

No anxiety disorder 470 2.6 (2.5) b

Panic disorder 9 6.7 (2.5) a

Anxiety disorder without panic disorder 190 4.9 (3.2) a


Social phobia 96 5.1 (3.1) a

Anxiety disorder without social phobia 107 4.9 (3.2) a


Specific phobia 40 5.7 (3.3) a

Anxiety disorder without specific phobia 163 4.8 (3.1) a

No anxiety disorder 470 2.6 (2.5)

b

Obsessive compulsive disorder 27 6.4 (2.9) a

Anxiety disorder without obsessive compulsive disorder 176 4.8 (3.1) a


Generalized anxiety disorder 39 5.6 (3.0) a

Anxiety disorder without generalized anxiety disorder 164 4.8 (3.2) a


Posttraumatic stress disorder 27 4.7 (3.1) a

Anxiety disorder without posttraumatic stress disorder 176 5.0 (3.2) a


Somatic problems

Major depressive disorder 34 4.8 (3.6) a

Panic or separation anxiety disorder without major depressive disorder 36 3.5 (3.2) ab

No major depressive, panic, or separation anxiety disorder 603 1.9 (2.3) b

Separation anxiety disorder 34 3.5 (3.7) ab

Panic or major depressive disorder without separation anxiety disorder 36 4.7 (3.2) a


Panic disorder 9 6.3 (2.5) a

Major depressive or separation anxiety disorder without panic disorder 61 3.8 (3.5) a


Attention-deficit/hyperactivity problems

Attention-deficit/hyperactivity disorder, combined type 84 9.1 (3.3) a

Attention-deficit/hyperactivity disorder, hyperactive type 10 8.7 (2.2) ab

Attention-deficit/hyperactivity disorder, inattentive type 97 6.4 (3.2) b

No attention-deficit/hyperactivity disorder 482 5.1 (3.6) c

Oppositional problems

Oppositional defiant disorder 158 6.3 (2.3) a

Conduct disorder or DBD NOS without oppositional defiant disorder 112 5.7 (2.8)

a

No oppositional defiant, conduct or DBD NOS disorder 403 3.5 (2.4) b

Conduct problems

Conduct disorder 77 12.8 (6.7) a

Oppositional defiant disorder or DBD NOS without conduct disorder 193 7.0 (4.9) b

No oppositional defiant, conduct or DBD NOS disorder 403 3.4 (3.4) c


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Discussion

Findings from this study provide support for the reliability

and validity of the expert judgment-derived DSM-Oriented

Scales in a large clinical sample of youth. Internal

consistency was favorable and convergent validity hypotheses

were almost uniformly supported across all scales. Divergent

validity results were also very favorable, though slightly moremixed than the convergent validity findings.

Several points warrant discussion. First, contrary to

prediction, significant relationships were found between the

DSM-Oriented Affective Problems scale and oppositional

and conduct indices. Although potentially surprising, these

findings are somewhat consistent with the literature. Namely,

depressive feelings in children can present as irritability

(American Psychiatric Association 2000) and previous

research has highlighted a moderate, but significant, rela-

tionship between oppositional/rule-breaking behavior and

feelings of depression (Goodman and Scott 1999; Loeber et

al. 2004). In some ways, this relationship can be seen ascorroborated within this investigation in that significant and

positive relationships were also found between DSM-

Oriented Oppositional and Conduct Problems Scales and

depressive indices.

Second, concerns have previously been raised regarding

the ability of the DSM-Oriented Scales to adequately measure

various DSM-Oriented constructs, particularly given that the

CBCL DSM-Oriented Scales contain relatively few items and

do not contain items comprising all DSM symptom criteria

(e.g., Kendall et al. 2007). Despite these concerns, findings of

the present study indicated that all CBCL DSM-Oriented

Scales were able to discriminate youths with and without

relevant DSM diagnoses. This finding runs counter to prior

research that suggested poor discriminative properties for the

DSM-Oriented Anxiety Problems Scale (Kendall et al. 2007;

van Lang et al. 2005). Specifically concerning this scale’s

performance in this study, it is also worth noting that this

scale could discriminate in predicted directions between

children with and without all major types of anxiety

disorders, despite being constructed only around conceptions

of GAD, SAD, and SPEC. With constituent items such as,

“Too fearful or anxious” and “Worries”, it seems that this

scale may not reflect specific diagnoses but rather anxiety

disorders in general.

Third, these overall findings are somewhat surprising

given that Vreugdenhil et al. (2006) found low concordance

between the YSR DSM-Oriented Scales and DSM DISC-C

diagnoses. However, it should be noted that Vreugdenhil et

al. examined YSR DSM-Oriented Scales (child report) with

incarcerated youths, whereas the present study examined

CBCL DSM-Oriented Scales (parent report) with an

outpatient sample. In addition, diagnoses in Vreugdenhil

et al.’s investigation were based on the DISC-C (child

report) while diagnoses in the present study were based on

the ADIS-IV-C/P as well as overall clinician impressions.

Accordingly, the differences between samples and mea-

surement approaches may account in part for these

seemingly competing findings.

Although the results of the present study are promising

with respect to the psychometric properties of the CBCL

DSM Oriented Scales, a few caveats are in order. First, inorder to maximize the size of the present sample, analyses

were performed across a pooled sample of participants

completing either the CBCL/4-18 or CBCL/6-18. Instru-

ment variance may have been decreased had all youths

filled out the CBCL/6-18. This was not possible, however,

given the timing with which the research clinic adopted the

CBCL/6-18 over the CBCL/4-18. However, it should again

be underscored that DSM-Oriented Anxiety, Somatic, or

Oppositional Problems Scale items and calculations were

identical across CBCL versions. Issues with missing items,

therefore, only applied to the DSM-Oriented Affective,

Oppositional, and Conduct scales, with the authors closelyadhering to CBCL/6-18 manual directions (Achenbach,

2001) for calculating DSM-Oriented Scales scores for

CBCL/4-18 instruments. Concerning potential differences

in the current study between CBCL/4-18 and CBCL/6-18

youth on demographic data, only one of seventeen

comparisons pointed to statistically significant differences

between these groups. Given the substantial size of

the CBCL/4-18 sample, noteworthy of mention is that the

authors also performed all study analyses with only the

CBCL/4-18 sample for comparative purposes against those

of the combined sample. Presenting these comparative

analyses is outside of the scope of this investigation.

However, it should be mentioned that all but two of the

results presented above were either replicated or in some

instances found stronger (i.e., in terms of direction and

statistical significance) for all analyses performed with the

CBCL/4-18 sample. Using only CBCL/4-18 youths, youths

with PTSD did not score higher than youths without PTSD

on the DSM-Oriented Anxiety Problems Scale and youths

with ADHD-PI did not score higher than youths without

ADHD-PI on the DSM-Oriented Oriented Attention-Deficit/

Hyperactivity Problems Scale. Given this study’s mixed

sample, it will be important for future studies examining

psychometric properties of the DSM-Oriented Scales to

collect data from large clinical samples with only the CBCL/

6-18 version.

Another limitation is that only the CBCL, and not the

Teacher Report Form (TRF) or Youth Self-Report (YSR),

was examined in this study. Consequently, the reliability

and validity findings for the DSM-Oriented Scales in the

present study generalize only to the CBCL. Psychometric

properties of the TRF and YSR DSM-Oriented scales in

large clinical samples thus remain open to future inquiry.


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Research following this study could build upon this

investigation’s limitations for furthering empirical scrutiny

of the psychometric properties of the CBCL’s DSM-

Oriented Scales. With this first validation study providing

the necessary foundation for subsequent psychometric

research, forthcoming investigations could perform com-

parative analyses between DSM-Oriented and Syndrome

Scales. For example, receiver operating characteristicscurve methodology could be used for comparing these

scales’ discriminative diagnostic abilities and choosing

optimal cut-points for making diagnostic decisions. In the

meantime, the strong performance of the DSM scales

suggests warranted supplemental usage with clinical pop-

ulations of youth.

Despite these limitations and indications for future

research, the present study is the first systematic investiga-

tion of the CBCL DSM-Oriented Scales’ psychometric

properties in a large clinical sample of youth. Findings lend

empirical support to the basic psychometric properties of

the clinical judgment-derived DSM-Oriented Scales.Results from the present investigation indicate acceptable

internal consistency for these scales as well as excellent

convergent and divergent validity. In conclusion, it appears

that the CBCL DSM-Oriented Scales may provide accurate

supplementary information that may be considered when

formulating clinical diagnoses.

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