Obsessive-Compulsive Scale of the Child Behavior Checklist: Specificity, Sensitivity, and Predictive Power Elliot C. Nelson, MD*; Gregory L. Hanna, MD‡; James J. Hudziak, MD§; Kelly N. Botteron, MD*; Andrew C. Heath, DPhil*; and Richard D. Todd, PhD, MD* ABSTRACT. Objective. To create an obsessive-com- ABBREVIATIONS. OCD, obsessive-compulsive disorder; CY- pulsive disorder subscale (OCS) of the Child Behavior BOCS, Children’s Yale-Brown Obsessional Scale; LOI-CV, Leyton Checklist (CBCL) and to determine its internal consis- Obsessional Inventory–Child Version; PPV, positive predictive tency, sensitivity, specificity, and positive and negative value; NPV, negative predictive value; CBCL, Child Behavior predictive power to identify obsessive-compulsive disor- Checklist; OCS, obsessive-compulsive subscale; DSM-IV, Diagnos- der (OCD) in children and adolescents. tic and Statistical Manual of Mental Disorders, Fourth Edition; DSM- III-R, Diagnostic and Statistical Manual of Mental Disorders, Third ؍ Methods. Three samples of equal size (n 73) of Edition, Revised. children and adolescents, matched for age, gender, and race, were selected for these analyses: 1) a clinically as- certained OCD group, 2) a psychiatrically treated group bsessive-compulsive disorder (OCD) is a whose records revealed no evidence of OCD, and 3) a much more prevalent illness than previously general population control group. An OCS was created appreciated. Although this premise is now O 1–5 by applying factor analysis to 11 CBCL items. Examina- widely accepted in adults, supporting data in chil- tions of internal consistency, sensitivity, specificity, dren and adolescents have accumulated more grad- and positive and negative predictive value were under- ually.6–12 Several studies of adolescents have found taken. lifetime prevalence rates for OCD6–12 ranging from Results. Of 11 items hypothesized to predict OCD, 8 1.9% to 4.1% with reported rates of subclinical symp- items were retained after factor analyses (smallest factor toms as high as 19%.11 This work, reports on auto- loading: 0.49) and used to calculate OCS scores. The immune-mediated OCD symptom exacerba- retained items displayed excellent internal consistency tions,13–15 and follow-up studies that suggested an OCD participants had .(0.84 ؍ Cronbach’s ␣ coefficient) improved prognosis for children and adolescents significantly higher OCS scores than either psychiatri- 16,17 cally treated or general population control groups. With who are treated for OCD have instilled in many the use of the 2 cutoff scores closest to the true rate of pediatricians a greater appreciation of the impor- OCD in the overall sample, sensitivity was 75.3% to tance of diagnosing OCD. 84.9%, specificity was 82.2% to 92.5%, positive predictive Classic presentations (eg, compulsive handwash- value was 70.5% to 83.3%, and negative predictive value ing) offer little challenge to even an inexperienced was 88.2% to 91.6%. diagnostician. OCD symptoms, however, may in- Conclusion. The performance of the proposed CBCL clude innumerable variants of obsessive thoughts OCS compares favorably with that of the only previously and compulsive behaviors that are decidedly more studied screening instrument for OCD, the Leyton Ob- challenging to recognize. In adult populations, re- sessional Inventory–Child Version. Unlike the Leyton searchers have struggled to produce standardized Obsessional Inventory–Child Version, the CBCL is al- instruments that capture sufficiently the phenome- ready in widespread use as a screen for most other forms nology of either obsessions or compulsions to enable of psychopathology. As the performance of the CBCL OCD to be diagnosed with reasonable validity.18,19 OCS will need to be replicated in other sample popula- Two instruments of demonstrated utility in adults tions, data with various cutoff levels are provided to have been revised for use in children and adoles- enable investigators and clinicians to tailor its use to cents. Like its adult counterpart, the Children’s Yale- specific study populations. Pediatrics 2001;108(1). URL: Brown Obsessional Scale (CY-BOCS) has demon- http://www.pediatrics.org/cgi/content/full/108/1/e14; strated good reliability and validity for the rating of Child Behavior Checklist, obsessive-compulsive disorder, 20 screening. OCD symptom severity, but it is not a diagnostic instrument. The Leyton Obsessional Inventory– Child Version (LOI-CV), a 20-item self-report adapted from the adult questionnaire,6,21,22 is the From the *Department of Psychiatry, Washington University School of only OCD screening instrument that has been stud- Medicine, St Louis, Missouri; ‡University of Michigan School of Medicine, Ann Arbor, Michigan; and §University of Vermont School of Medicine, ied previously. In an investigation that used a 2-stage 6,21 Burlington, Vermont. design, all high school students in a New Jersey Received for publication Oct 24, 2000; accepted Mar 26, 2001. county first were asked to complete a number of Reprint requests to (E.C.N.) Washington University School of Medicine, self-report measures, including the LOI-CV. A strat- Department of Psychiatry, 40 N Kingshighway, Suite 1, St Louis, MO 63108. E-mail: [email protected] ified random sample in which participants who had PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- high scores on the LOI-CV or 1 of the other question- emy of Pediatrics. naires were overrepresented was then selected for http://www.pediatrics.org/cgi/content/full/108/1/Downloaded from www.aappublications.org/newse14 by guest PEDIATRICSon September 28, Vol.2021 108 No. 1 July 2001 1of5 interview by clinicians who were blind to question- used to identify 110 children and adolescents who had received a naire results. The LOI-CV was found to have reason- diagnosis of OCD during their treatment. No CBCL data were available for 30 of these individuals. The clinical information for able sensitivity and specificity (75%–88% and 77%– the remainder was reviewed by a psychiatrist (E.N.) with ade- 84%, respectively, depending on the cutoff used) but quate support found for a Diagnostic and Statistical Manual of only modest positive predictive value (PPV; 15%– Mental Disorders, Fourth Edition (DSM-IV),32 diagnosis of OCD in 18%). A screening instrument should have reason- 45 participants. Comorbid diagnostic information was obtained able PPV and high negative predictive value (NPV). from the initial clinical evaluation performed either by or under the direct supervision of a board-certified child and adolescent The LOI-CV’s high rate of false positives, coupled psychiatrist. Age limitations led to the exclusion of an additional with its lack of applicability other than for OCD, may 8 children aged 7 years or younger as the youngest individuals in explain why it has had only limited use in research the general population control group were 9 years of age (a or clinical practice. decision was made to allow no more than a 1-year age difference 23 for matching). Data on an additional 36 participants with OCD The Child Behavior Checklist (CBCL) is one of ascertained via presentation (beginning in 1987) for treatment and the most widely used instruments in child and ado- research protocols at the UCLA Neuropsychiatric Institute and the lescent psychiatry and pediatrics. It is understood University of Michigan were made available for inclusion in the easily and completed readily by most parents. Avail- present analyses. Diagnostic and Statistical Manual of Mental Disor- 33 able programs enable the generation of scores for 8 ders, Third Edition, Revised (DSM-III-R) OCD and comorbid diag- noses were confirmed by a board-certified child and adolescent quantitatively derived CBCL syndrome scales. The psychiatrist (G.H.). The CBCL data of 24 of these participants were scales are normalized for age and gender.23 The re- published previously.29 liability, validity, and temporal stability of the A group of 73 psychiatrically ill control participants was ob- CBCL’s scales have been documented thoroughly.23 tained from the St Louis Children’s Hospital Child Psychiatry Center. Participants were selected via a program that generated Investigators increasingly have used the CBCL in random numbers that then were compared with previously as- clinically characterized populations to use it as a tool signed unique clinic numbers. Participants who matched an OCD for predicting Diagnostic and Statistic Manual of Men- group member in terms of age, gender, and race were included on tal Disorders (DSM) diagnoses.24–28 this basis. As this process progressed, a billing record search was Previous examinations that used the CBCL in chil- used to locate control participants for individuals who were not readily matched. The exclusion criteria for the control participants dren and adolescents with OCD reported consistent were the lack of a CBCL or documentation of OCD symptoms in results with elevation of thought problem and anx- their medical record. Diagnostic information also was obtained for ious-depressed syndrome scores.29–31 Hanna29 found these participants from the initial clinical evaluation performed no significant correlation between any CBCL syn- either by or under the direct supervision of a board-certified child and adolescent psychiatrist. drome score and the CY-BOCS and noted that sev- A general population control group was selected from the 1992 eral CBCL syndrome scores differed significantly be- Vermont national sample.23 These participants were chosen ran- tween participants with and without comorbid domly to match OCD participants in terms of age, gender, and disruptive behavior disorders. race. Each group consisted of 45 boys and 28 girls and included 1 The current investigation uses factor analysis to Asian and 1 Hispanic boy. All other participants were white, non-Hispanic. The respective mean ages in years of the boys in the examine CBCL data derived from clinically ascer- OCD group, psychiatrically ill controls, and population controls tained children and adolescents with OCD (n ϭ 73) were 12.27 (SD: 2.77), 12.24 (SD: 2.80), and 12.31 (SD: 2.70), respec- and 2 gender-, race-, and age-matched control tively.