295

ORIGINAL

ARTICLE

Validity of Autism Behavior Checklist (ABC):

preliminary study
Validade do Inventrio de Comportamentos
Autsticos (ICA): estudo preliminar
Mrcia Regina Fumagalli Marteleto,1
Mrcia Regina Marcondes Pedromnico1
Original version accepted in Por tuguese

Abstract
Objective: To examine the concurrent and criterion validity of the Autism Behavior Checklist (ABC). Methods: Three groups,
comprising 38 mothers of children previously diagnosed with autism (DSM IV-TR, 2002), 43 mothers of children with language
disorders other than autism, and 52 mothers of children who had no linguistic or behavioral complaints, were interviewed. In
order to minimize the effect of maternal level of education, the questionnaire was completed by the researcher. To determine the
concurrent validation, ANOVA and discriminant analysis were used. The ROC curve was used to establish the cutoff score of the
sample and to examine the criterion validity. Results: The mean total score was significantly higher in the group of mothers of
autistic children than in the other groups. The ABC correctly identified 81.6% of the autistic children. The ROC curve cutoff score
was 49, and the sensitivity was 92.1%, higher than the 57.89% found when a cutoff score of 68 was used. The specificity was
92.6%, similar to the 94.73% obtained with a cutoff score of 68. Conclusions: The ABC shows promise as an instrument for
identifying children with autistic disorders, both in clinical and educational contexts, especially when a cutoff score of 49 is used.
Keywords: Autistic disorder; Diagnostic and statistical manual of mental disorders; Diagnosis, differential; Validation studies
[Publication type]; Questionnaires
Resumo
Objetivo: Examinar a Validade Concorrente e a Validade de Critrio do Inventrio de Comportamentos Autsticos (ICA). Mtodos:
Foram entrevistadas, com a escala, mes de crianas com diagnstico de transtorno autista, previamente estabelecido por
especialistas na rea. Para comparao, foram tambm entrevistadas mes de crianas com transtorno de linguagem e mes de
escolares sem queixas de problemas de linguagem e comportamento social. Os trs grupos foram assim constitudos: GTA: 38
mes de crianas com transtorno autista (DSM IV-TR, 2002), GTL: 43 mes de crianas com transtorno de linguagem (DSM IV-TR, 2002)
e GET: 52 mes de crianas escolares tpicas. O questionrio foi preenchido sob forma de entrevista para minimizar os efeitos da
escolaridade materna. ANOVA e anlise discriminante foram usadas para examinar a Validade Concorrente. A curva ROC foi usada
para estabelecer o ponto de corte da amostra e para examinar a Validade de Critrio. Resultados: O Inventrio de Comportamentos Autsticos identificou corretamente 81,6% das crianas com autismo, sendo o escore mdio total do GTA significantemente
(p < 0,001) maior que os outros dois grupos de crianas. O Inventrio de Comportamentos Autsticos mostrou baixa sensibilidade
(57,89%) e alta especificidade (94,73%) quando se usou a nota de corte 68 pontos; diminuda a nota de corte para 49 pontos
obtida pela curva ROC, a sensibilidade da escala aumentou (92,1%) e a especificidade se manteve alta (92,6%). Concluses:
O Inventrio de Comportamentos Autsticos um instrumento promissor para identificar crianas com autismo, especialmente
com ponto de corte 49, tanto na clnica como em contextos educacionais.
Descritores: Transtorno autstico; Manual diagnstico e estatstico de transtornos mentais; Diagnstico diferencial; Validade;
Questionrios
Academic thesis conducted with financial support provided by the Conselho Nacional de Pesquisa e Desenvolvimento/Coordenao de
Aperfeioamento de Pessoal de Nvel Superior (CNPq/CAPES) and entitled: Validity and Reliability of the Autism Behavior Checklist
(ABC): Preliminary study, March 2003, presented to the Pediatric Department of the Universidade Federal de So Paulo.
1

Department of Speech Therapy, Federal University of So Paulo (UNIFESP), So Paulo (SP), Brazil (Psychologists)

Financing: Coordenao de Aperfeioamento de Pessoal de

Nvel Superior (CAPES)
Conflict of interests: None
Submitted: 18 August 2004
Accepted: 31 January 2005

Correspondence
Mrcia Regina Fumagalli Marteleto
Disciplina de Distrbios da Comunicao Humana,
Departamento de Fonoaudiologia
Rua Botucatu, 802 - Vila Clementino
04023-900 So Paulo, SP, Brazil
Phone/Fax: (11) 5549-7500.
E-mail: marcia.marteleto@terra.com.br
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296 Marteleto MRF & Pedromnico MRM

Introduction
Autism is a severe, chronic development disorder, involving
marked retardation of aptitudes for social interaction,
communication and play.1
The detection of autism and other general developmental
disorders in very young children is quite difficult since delayed
development may not be identified until the child is given the
opportunity to interact in social environments other than the
family setting. In addition, at the most severe levels, the
differential diagnosis between autism and mental retardation
is more difficult, especially among children of preschool age.2
Early diagnosis is very important since the sooner the
recommended orientation of procedures is carried out, the
more likely it is that such children will develop social and
communicative skills, and the less stereotyped their
behavior will be.
Regarding psychometric scales and psychological tests, there
are few instruments that have been validated for the evaluation
of Brazilian children under 6 years of age, and still fewer that
have been validated for the evaluation of Brazilian children
with autism or similar disorders. Therefore, to further research
and clinical treatment, it is necessary that protocols for the
evaluation of these groups of children be systematized.
In 2003, the validity of the Child Behavior Checklist (CBCL)3
for identifying children with autism was examined.4 The authors
used the CBCL to interview 38 mothers of children with autism
(mean age, 7.4 years), 31 mothers of children with other
psychiatric disorders (mean age, 7.8 years) and 34 mothers
of typical students (mean age, 7.0 years). Using logistic
regression models, those authors identified combinations of
CBCL scales that distinguished the groups. The results
suggested that the CBCL is a promising instrument for identifying
children with autism. In 2004,5 another study involving use of
the CBCL identified the most frequent behavior problems in
autistic children, discussing differences between speaking and
nonspeaking children. In general, speaking and nonspeaking
autistic children both presented behavior problems and more
complaints of thinking problems.
The second edition of the Autism Screening Instrument for
Educational Planning study (ASIEP-2 study)6-7 was initiated in
2001 and presented in 2002.8
The ASIEP-2 is a screening instrument used to evaluate the
autistic profile of children suspected of having this pathology
and to create educational plans for such children. It consists
of five subscales: the Autism Behavior Checklist (ABC), the
Sample of Vocal Behavior, Interaction Assessment, Educational
Assessment and Learning Rate Prognosis. It was designed in
the 1980s and revised in 1993 in most of the United States
and Canada. The material was administered by a
multiprofessional team (psychologists, speech therapists,
teachers and pediatricians) in special education schools whose
students presented autism, hearing impairment, mental
retardation, visual impairment or other disorders.
The ABC consists of a list of atypical behaviors characteristic of
the pathology and is designed for the triage of children suspected
of having this disorder, contributing to the differential diagnosis
and the referral of such children to educational intervention.
Due to its easy application and low cost, it has been used by
health professionals in various countries, in research and in
clinical practice. Some studies have used the questionnaire in
interviews with the parents of such children.9-10
The psychometric properties of the ABC have been investigated
and evaluated for some years. Although the scale presents
Rev Bras Psiquiatr. 2005;27(4):295-301

little psychometric power, it has been considered useful in

the screening of the children suspected of having autism.
The standardization of the ABC occurred in three stages.
Initially, the authors 6 selected the atypical behaviors most
frequently presented by the autistic patients from other scales
used in the diagnosis of autism. Second, they mailed the list
of behaviors to experienced professionals in the area of autism,
who returned it to the authors after modifying and excluding
behaviors from the list. The modified questionnaires were sent
to 3000 professionals in the area of special education, who
were asked to apply the scale through the observation of the
children, identifying them by gender, age, diagnosis, and
whether they were living in the institution or with the family.
A total of 1049 questionnaires were returned to the authors.
Statistical analyses determined the weight (score: 1 to 4) of
each behavior, according to the degree to which it correlated
with the pathology, a score of 4 representing the strongest
correlation. The final version of the questionnaire addresses
57 atypical behaviors related to five areas: 1) sensory stimuli
sensorial; 2) relating; 3) body and object use; 4) language;
and 5) social self-help. The behaviors of the five areas are
distributed at random on a registry form on which the observer
notes the current behavior of the child. The weights of the
behaviors identified are totaled by area, and those are in turn
totaled to obtain the overall score. The authors proposed that
children presenting overall scores equal to or greater than 68
points be classified as autistic.6-7 Scores between 54 and 67 points
are considered to represent moderate probability of classification
as autistic, and scores between 47 and 53 points are
considered inconclusive. When the score is below 47 points,
the child is not considered autistic.
Since the creation of the ASIEP-2, many studies using the
ABC have been carried out in attempts to check its validity
and reliability.10-21
The capacity of ABC to correctly evaluate children
suspected of having autism using the cutoff point of 68
has been questioned. 13-14,16-19 The results of such studies,
however, var y significantly regarding the sample selection
criteria and methodology.
The validity of the scale was also examined in a study carried
out by Miranda-Linn and Melin, who compared the total score
of the scale, by area and by item, between speaking and
nonspeaking autistic individuals.20 The sample was composed
of the members of the National Society for Autistic Children in
Sweden (NSACS). Initially, cover letters and two questionnaires
were sent to 2052 NSACS members, who were asked to
administer the questionnaires to parents who volunteered to
participate in the study. The first questionnaire addressed the
age of the individuals, gender, laterality, diagnosis, age at time
of diagnosis, age at onset of symptoms, presentation form of
symptoms, cognitive disorders, verbal communication and
family history of neuropsychiatric pathologies. The second
questionnaire was a modified version of the ABC and included
the list of behavioral symptoms frequently presented by
individuals with autism. A total of 1596 NSACS members
returned the questionnaires, and 497 were fond to be correctly
filled out. Based on data collected in these questionnaires,
the authors classified the language level of the children and
adolescents. Individuals who had never spoken, or who had
once spoken but were currently mute, were classified as mute,
and those who presented spontaneous utterances were
classified as speaking. The children and adolescents were
then divided into two groups: 155 nonspeaking individuals

Validity of ICA 297

(66% boys and 34% girls), and 335 speaking individuals (70%
boys and 30% girls). The authors found a total mean score of
59.90 for nonspeaking individuals and 54.86 for speaking
individuals. There was no significant difference between the
two groups in mean score. The mean scores obtained in the
two groups were both lower than the 68-point cutoff proposed
by Krug et al. 6-7 In their study, Miranda-Linn and Melin 20
confirmed the proposals of other authors to decrease the 68point cutoff score, considering it too high to correctly identify
children with autism, and suggested a cutoff score of 54.
In one study, children with autism and children with mental retardation were compared using the ABC together with
two other ASIEP-2 subscales (Interaction Assessment and
Educational Evaluation). 13 The authors correctly classified
100% of the children with autistic disorder and 95% of the
children with mental retardation.
In general, only approximately 50% of children with autism
are identified when the cutoff point proposed by the authors of
the ABC is used, whereas the discriminative capacity of the
questionnaire increases significantly when the cutoff point is
lowered. 14,16-19
Based on the questions arising from these studies, the
present article proposes to examine the concurrent and
criterion validity of the ABC.
Methods
1. Par ticipants
This study involved mothers of children previously diagnosed
with autism, from two institutions of the city of So Paulo that
work exclusively with programs of behavioral and educational
intervention for autism: the Friends of Autism Association and
the Speech Disorders Outpatient Clinic of the Universidade
Federal de So Paulo (UNIFESP). The children were diagnosed
by a multiprofessional team specialized in interviewing parents,
were submitted to clinical evaluation and were diagnosed with
autism.1 Since language problems constitute one of the criteria
for the diagnosis of autism, mothers of children diagnosed
with speech disorders 1 but without autism, all undergoing
speech therapy at the UNIFESP Speech Disorders Outpatient
Clinic, were also invited to participate in the study. With the
objective of having a comparison group without speech
problems or autism complaints, mothers of school children
from an educational program in a school associated with
UNIFESP were also invited to participate. This study involved
38 mothers of children with autistic disorder, designated the
autistic disorder group (ADG), 43 mothers of children with
language disorder, designated the language disorder group
(LDG), and 52 mothers of children without autism or language
problems, designated the typical schoolchild group (TSG).
2. Adaptation of the instrument
For the prevalidation of the ABC, the questionnaire was
initially translated from English into Por tuguese. A backtranslation was then carried out by a professional proficient in
the English language. Subsequently, the questionnaire was
administered to 6 mothers, 1 of mother of a child diagnosed
with autism and 5 mothers of typical students. This test was
administered with the objective of determining whether the
translation needed to be adapted; these protocols were not
included in the validation study.
During the administration of the test, items 13, 16, 19, 20,
21, 22, 23, 25, 29, 37, 38, 48, 49, 51 and 52 required
further explanation for the mothers to understand their

meaning. In order to eliminate the need for such elaboration,

those items were adapted to colloquial language, without
changing the meaning of the question. After these changes
in the questionnaire, we considered the ABC translated and
adapted to Brazilian culture. We entitled it the Inventrio de
Comportamentos Autsticos (a direct translation of Autism
Behavior Checklist).
We present herein the registry form, adapted and translated
into Brazilian Portuguese8 (Table 1).
3. Procedure
In order to minimize the effect of maternal level of education,
the ABC was administered to all of the mothers as an interview
conducted by the psychologist responsible for the study. The
mothers answered yes or no regarding the presence of a given
behavior. The partial scores were then calculated and totaled
to obtain the overall score for each child.
4. Data analysis
The concurrent validity refers to making comparisons between
individuals previously diagnosed with autism and those
diagnosed with other pathologies, with the aim of demonstrating
that the test distinguishes the behavior of an individual
presenting the chosen behavior from that of other individuals
in different groups.22 We used analysis of variance (ANOVA)
to compare averages of independent samples and discriminant
analysis to evaluate how well the score would be able to
distinguish among the three study groups.
The criterion validity refers to the effectiveness of a test to
predict the behavior of the individual in predetermined
situations. In this type of validation, indices are calculated
using standard mathematical formulas. Sensitivity is the
capacity of the test to detect the disease, and specificity refers
to the capacity of the test to detect the absence of the disease.22
In the present study, the initial criterion for the test of positivity
was that established by the authors of the instrument6-7 (all
children obtaining a score of 67/68 points were considered
positive). We later built the ROC curve with the aim of finding
the cutoff point for our sample.
This study was approved by the UNIFESP Ethics in Research
Committee (process no. 316/01).
Results
1. Description of the sample
Within the study sample, the ADG consisted of 32 boys
(84.21%) and 6 girls (15.79%), the LDG of 29 boys (67.44%)
and 14 girls (32.56%) and the TSG of 25 boys (48.08%) and
27 girls (51.92%).
Mean age was 7 years and 5 months, with a standard
deviation (SD) of 2.8 in the ADG, 6 years and 9 months
(SD = 2.3) in the LDG, and 7 years and 7 months (SD = 1.8)
in the TSG. There were no significant differences among the
three groups in terms of age.
In the ADG, 81.58% of the children were in preschool,
whereas 78.85% of the TSG children were in elementary
school. Among the LDG children, 41.86% were in preschool,
and 41.86% were in elementary school.
In the ADG and TSG, the mean maternal level of education
was 9 years of schooling, compared with 6 years in the LDG.
In the LDG, mean maternal level of education was significantly
lower (p < 0.001) than that found for the other two groups.
A significant difference was found among the groups
with regard to mean monthly income, and the ADG was
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Rev Bras Psiquiatr. 2005;27(4):295-301

Validity of ICA 299

identified as the group presenting the highest such income

(R$ 2,251.59).
2. Concurrent validity
After it had been confirmed that the data followed a normal
distribution, the mean and SD of the total score were calculated
for each group of participants. The percentage of children
correctly identified by discriminant analysis was also calculated
for each group.
Table 2 presents the ANOVA means and SDs found for
the total ABC scores, as well as the discriminant analysis
showing the percentage of children correctly classified in
each of the groups.
We observed that the total mean score for the ADG children
was significantly higher than that for children in the other
two groups (p < 0.001), as well as being higher than the 68point cutoff proposed by the authors of the test.6-7 Total mean
score for the LDG children was significantly higher than that
for the TSG children (p < 0.001) and lower than that for the
ADG children.
In the ADG and TSG, 81.6% and 84.6% of the children,
respectively, were correctly classified. However, only 44.2%
of the children in the LDG were correctly classified.
3. Criterion validity
Figure 1 shows the ROC curve of the ABC. The area under
the curve was found to be 0.937 (95% CI = 0.892-0.982),
which indicates that children with autism can be satisfactorily
identified using the total score. The suggested cutoff point
was 49 points.
Table 3 shows the validity indices for the ABC, considering
the cutoff points: 67/68 and 48/49.
At cutoff point 67/68, we observed that the instrument
presented low sensitivity (57.89%) and high specificity
(94.73%) in identifying children with autistic disorder in the
population. At cutoff point 48/49, the sensitivity of the
instrument increased (92.11%), and the specificity remained
high (92.63%).
Discussion
This study showed the validity of the ABC in distinguishing
children with autism from children with language disorders
and from those without complaints.
This instrument correctly classified 81.6% of the children
with autism, and the total mean score was 72.736 (19,548),
similar to that proposed by the authors of the instrument.6-7
These data suggest that the ABC is useful and should be
included in the protocol for investigating children suspected
of having autism. Other studies have found similar results.
Two studies13-21 correctly classified 100% and 85%, respectively,
of the children evaluated. However, such results were not

obtained in other studies,14-17 in which only 50% of the children

were correctly classified. Neither speaking nor nonspeaking
autistic children were correctly classified at cutoff point 68.20
When we tested the criterion validity of the instrument using
the 67/68 cutoff point, we found that the sensitivity (57%)
and specificity (94.73%) were the same as those obtained in
the validation study developed in 1988.14 Using the 48/49
cutoff point indicated in our sample, the sensitivity of the ABC
significantly increased to 92.11% and the specificity of the
instrument remained high, meaning that the ABC is capable
of identifying the children who do not have autistic disorder,
even among children with other pathologies.
We observed that the instrument correctly classified 44%
of the children in the LDG. This suggests that there is a
need to precisely characterize the language phenotypes of
children with autism. 23 In children with developmental
problems, the younger the child, the more difficult the
establishment of the differential diagnosis is since delayed
language development is a common characteristic of many
childhood mental disorders. We emphasize that the ABC
should be used for its intended purpose (the screening of
children suspected of having autism), together with
instruments used to evaluate the other various mental aspects,
such as language, cognition and social skills.
In this study, the power of the instrument in screening
children presenting a high probability of having autism
increased when a lower cutoff point was used. Previous
studies16-19 have called into question the cutoff point suggested
by the authors of the instrument.
In the studies previously mentioned,14,16-20 the great variation
in the age of the participants may be suggested as an explanation
for the different cutoff points obtained. From our point of view,
the behavioral phenotype of the child with autism suffers the
effect of the development process. As the child grows, there is
a change in the course of the disease, and the child tends to
present other behaviors characteristic of the pathology,24 even
when in special treatment programs. In our study, we tried to

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300 Marteleto MRF & Pedromnico MRM

reduce the age bracket of the children in order to minimize the

variability in the behavioral manifestation. The fact that we found
the appropriate cutoff point to be lower than that suggested by
the authors of the instrument led us to consider another important
factor: the level of severity of autism in that child. For example,
speaking is considered a sign of less severity of the pathology in
the child with autism, even with changes of form and content
characteristic of the verbal language of this group of children.1
In the ABC, seven of the thirteen behaviors described in the area
of language are those atypical of the profile: repetition of sounds,
words and phrases, inappropriate use of pronouns and prosodic
alterations; and these were the ones with the highest score (3 or
4). We understand that the speaking child with autism will receive
more points, increasing the probability of being identified and

Acknowledgments
We thank the Associao Amigos do Autista (AMA-SP), the Ambulatrio dos Distrbios da Comunicao Humana da UNIFESP, the Escola Paulistinha de Educao, the Centro de Recreao da UNIFESP
and Capes/CNPq. We also thank Prof. Dr. Jacy Perissinoto and Prof.
Me. Ana Carina Tamanaha, partners in studies on autism, and Prof.
Me. Ellen Osborn for the back-translation.

benefiting from the interventions offered in specialized educational

programs. However, the nonspeaking child with autism, with
more nonverbal stereotypies, may be incorrectly classified as being
at a lower risk for autism. Therefore, further studies are necessary.
Such studies should examine the ABC in groups of children with
different degrees of severity, and even within the variations of the
profiles included in the autistic spectrum.
In conclusion, despite the limitations of our study (the small
sample size, the variability in the ages of the subject, and the
fact that the severity of the disorder was no determined in the
study group), our results suggest that the ABC is a useful screening
instrument in the identification of children with autism, in clinical
and educational contexts, with higher probability when a cutoff
point of 49 is used.

5.

6.

7.

8.

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