ARTICLE

The Child Behavior Checklist and Related Forms for

Assessing Behavioral/Emotional Problems and
Competencies
Thomas M. Achenbach, PhD,* and Thomas M. Ruffle, MD
problems. The version of the CBCL
OBJECTIVES: for ages 2 and 3 years (CBCL/2 to
After completing this article, readers should be able to: 3) can be completed by parents in
about 10 minutes. The version for
1. List the types of behavioral and emotional problems that primary ages 4 to 18 years (CBCL/4 to
care physicians who work with children must address. 18) includes competence items and
2. Describe the data required from parents, children, teachers, and problems. The problem items can be
child care practitioners for assessment of behavioral and emotional
problems.
completed by most parents in about
3. Describe systems of questionnaires that can be used for obtaining 10 minutes, and the (optional) com-
standardized assessment data. petence items require an additional
5 to 10 minutes. The CBCL is self-
explanatory and can be filled out in
a waiting room or can be sent home
Introduction tivity disorder (ADHD), are widely
for completion. If a parent is unable
Primary care physicians who work publicized as candidates for medical
management. Concerned parents, to complete the CBCL indepen-
with children must deal with a great dently, a receptionist or other staff
variety of behavioral and emotional therefore, may request that pediatri-
cians and family practitioners evalu- member can read the items aloud
problems. The system described in and enter the parents answers while
this article provides low-cost, stan- ate their children for ADHD. To
assess ADHD and other behavioral the parent follows along on a second
dardized assessment and documenta- copy. For parents whose English
tion of such problems and requires and emotional problems, physicians
need information from people who skills are poor but who can read
little effort by the physician. other languages, translations are
Primary care physicians are under see children in their everyday con-
texts. Parents and parent-surrogates available in 58 languages.
increasing pressure to obtain stan- Figure 1 shows the CBCL/2 to 3
dardized documentation for the con- are the primary sources of such
information for most children. Older filled out for 3-year-old Adam Stern
ditions they encounter. The most by his mother. For each problem
obvious pressures stem from man- children can contribute useful infor-
mation about their own functioning. item, parents circle 0 if the item is
aged care. Among the most fre- not true of their child, 1 if the item
quently imposed expectations of Teachers are especially important
sources of information when chil- is somewhat or sometimes true, and
primary care physicians are to: 2 if the item is very true or often
drens functioning in school is rele-
Be gatekeepers for most forms of vant, such as when ADHD is true. Problem items on the CBCL/
care needed by patients. suspected. 4 to 18 resemble those on the
Offer increasingly diverse services There are no litmus tests to deter- CBCL/2 to 3, except that parents
to more patients while limiting the mine precisely which children have rate the CBCL/4 to 18 problem
time spent with each patient. behavioral or emotional disorders. items for the preceding 6 months
Provide extensive documentation Furthermore, even when a childs instead of the 2 months specified on
for assessments of patients and for behavior is clearly problematic, the CBCL/2 to 3. Competence items
treatment and referral. detailed documentation is needed to on the CBCL/4 to 18 assess the
pinpoint the specific areas in which childs activities, social relations,
To fulfill these expectations, physi- and school functioning.
cians need cost-effective procedures the childs behavior deviates from
norms for age and gender. Such The data obtained with the CBCL
for obtaining, using, and transmit- are summarized on a profile that
ting information about patients. documentation is needed for decid-
ing what action to take, advising displays the parents ratings of each
Childrens behavioral and emo- item. The profile also displays the
tional problems pose special chal- parents, communicating with mental
health and special education person- childs standing on syndromes of
lenges for meeting such managed problems that were derived from
care requirements. Certain types of nel, and referring to specialists.
statistical analyses of CBCLs filled
behavioral problems, such as those out for large numbers of clinically
ascribed to attention deficit hyperac- referred children. Each syndrome
The Child Behavior consists of problems that were found
Checklist (CBCL) to occur concomitantly. Figure 2
*Departments of Psychiatry and Psychology,
University of Vermont, Burlington, VT. The CBCL is a standardized form displays the profile for Adam Stern

Vermont Child Development Clinic, that parents fill out to describe their that was scored from the CBCL/2 to
Burlington, VT. childrens behavioral and emotional 3 filled out by his mother.

Pediatrics in Review Vol. 21 No. 1 August 2000 265

 CHILD DEVELOPMENT
Developmental Assessment

Figure 2 documents that Ms. Stern

reported considerably more aggres-
sive behavior for Adam than is
reported by parents of most 3-year-
olds as well as somewhat more
sleep problems and somatic prob-
lems without known medical causes.
The borderline and clinical ranges
shown on the profiles provide guide-
lines for identifying scores that are
moderately to very deviant com-
pared with scores obtained by nor-
mative samples of childrens peers.
These guidelines are flexible in that
users can tailor their choice of cut-
points to their particular caseloads
and to the types of decisions needed
in individual cases. For example,
users may elect to apply lower cut-
points to scores on the anxious/de-
pressed, aggressive behavior, and
destructive behavior scales of the
CBCL/2 to 3 and to scores on the
attention problems scale of the
CBCL/4 to 18. Because these syn-
dromes comprise large numbers of
potentially troublesome problems,
lower cutpoints often may be war-
ranted than for syndromes that com-
prise fewer and less troublesome
problems. Furthermore, scores that
fail to reach cutpoints may indicate
a need for diagnostic evaluations for
conditions such as anxiety disorders,
depression, oppositional-defiant dis-
order, ADHD, and conduct disorder.
In the forthcoming 21st century edi-
tions of the profiles, lower cutpoints
will be indicated explicitly on the
FIGURE 1. Child Behavior Checklist for Ages 2 to 3 filled out for Adam Stern. profiles. Regardless of where clini-
cal cutpoints are set, parents may be
duly concerned when their children
As illustrated in Figure 2, the BORDERLINE AND CLINICAL manifest behavioral or emotional
CBCL/2 to 3 syndromes are desig- RANGES problems, and such concerns always
nated in six areas: anxious/de- The broken lines on the profile should be taken seriously and han-
pressed, withdrawn, sleep problems, shown in Figure 2 indicate a border- dled judiciously. In addition to prob-
somatic problems, aggressive behav- line range between the normal and lems, the 21st century CBCL for
ior, and destructive behavior. clinical ranges. Scores that are preschoolers (available in Fall 2000)
Adams score on each syndrome includes a screen for language
below the bottom broken line (95th
consists of the sum of numbers that delays.
percentile) are in the normal range,
his mother circled on the individual
and those that are above the top bro-
items that comprise the syndrome.
The left side of the profile delin- ken line (98th percentile) are in the HOW TO USE CBCL FINDINGS
eates the percentile of the national clinical range. Scores between the The physician can use the findings
normative sample for each syndrome broken lines are high enough to be in patient profiles in a variety of
score. For example, Adams score of concern, but not high enough to ways. For example, if Ms. Stern
on the anxious/depressed syndrome be considered very deviant. Adam completed the CBCL as part of
is at the 69th percentile, which obtained scores in the borderline Adams regular physical examina-
means that 69% of the children in range on the sleep problems and tion, the physician can ask her a few
the national normative sample somatic problems syndromes, but in questions to determine her level of
obtained scores at or below the the clinical range on the aggressive concern about Adams high level of
score that Adam obtained. behavior syndrome. The profile in aggressive behavior and his moder-

266 Pediatrics in Review Vol. 21 No. 1 August 2000

 CHILD DEVELOPMENT
Developmental Assessment

FIGURE 2. Hand-scored profile for Adam Stern from the CBCL/2 to 3 completed by his mother.

ately high levels of sleep and take home a CBCL for Mr. Stern to nor the C-TRFs reflect much aggres-
somatic problems. The physician complete and return. sion, this would suggest that Adams
then can offer guidance and deter- aggressive behavior occurs primarily
mine whether further evaluation is in interactions with Ms. Stern or that
indicated. It may be important to The Caregiver-Teacher she is especially sensitive to behav-
evaluate, for example, whether the Report Form (C-TRF) iors that are less salient to others.
elevated sleep and somatic problems If Adam attends child care or pre- The fact that only one informant
reflect an undetected medical condi- school, the Sterns could be asked to reports high levels of particular
tion, a response to specific stressors, have staff members each complete types of problems, such as aggres-
or a long-term pattern. and mail in the C-TRF, which has sive behavior, does not necessarily
If the Sterns are covered by a many of the same items as the mean that the informant is either
managed care plan, Adams profile CBCL. This allows the physician to inaccurate or the cause of the childs
can be used to document needs for compare the two resulting profiles. problems. There are numerous rea-
additional services, which might If both the CBCL completed by sons why childrens problems may
include further assessment to ascer- Mr. Stern and the C-TRFs are con- be especially salient in one situation
tain the causes of the sleep and sistent with the CBCL completed by or to one informant. A major benefit
somatic problems, as well as the Ms. Stern in revealing high levels of of using parallel assessment forms is
pervasiveness of the aggressive aggression, a need for help by a that they explicitly document both
behavior. If the managed care plan psychologist, psychiatrist, or other inconsistencies and consistencies in
encourages the physician to assess mental health specialist is substanti- how childrens functioning is seen
behavioral problems further, the ated. On the other hand, if neither across a variety of situations and
physician could ask Ms. Stern to the CBCL completed by Mr. Stern interaction partners. The informant-

Pediatrics in Review Vol. 21 No. 1 August 2000 267

 CHILD DEVELOPMENT
Developmental Assessment

in addition to the 5 minutes needed to

score the problems. Computer scoring
of the competencies is considerably
faster and easier than hand-scoring.

COMPUTER SCORING
The most efficient method of scor-
ing forms is via computer with a
software package that is compatible
with most computers. Personnel who
are familiar with word processing
can use the software to score all the
forms.
Figure 3 shows a computer-
scored profile for the CBCL/4 to 18
that was completed for 14-year-old
Megan Dunn by her father. The pro-
file is analogous to the hand-scored
profile previously illustrated for
3-year-old Adam Stern, although the
syndromes of problem items differ
somewhat. For example, the CBCL/
4 to 18 profile includes a syndrome
designated as attention problems that
includes many of the types of prob-
lems that are ascribed to ADHD.
The CBCL/4 to 18 profile also
includes a syndrome designated as
delinquent behavior, which com-
prises unaggressive conduct prob-
lems, such as lying, stealing, tru-
ancy, and substance use. Together,
FIGURE 3. Computer-scored profile for Megan Dunn from the CBCL/4 to 18 the CBCL/4 to 18 delinquent behav-
completed by her father. ior and aggressive behavior syn-
dromes include most of the behav-
specific aspects of the reports may For example, when Ms. Stern iors that are combined in the
be as valuable as the aspects that are arrived for Adams appointment conduct disorder category of the
consistent across multiple infor- with his doctor, the doctors recep- fourth edition of the American Psy-
mants. For example, if Ms. Stern is tionist gave Ms. Stern the CBCL/ chiatric Associations Diagnostic
the only informant who reports 2 to 3 to fill out in the waiting room and Statistical Manual (DSM-IV).
aggressive behavior, it would be and made herself available to The CBCL/4 to 18 profile has these
helpful to ask her about the circum- answer questions about the form. separate scales because statistical
stances in which she observes After Ms. Stern completed the analyses yielded separate syndromes
aggressive behavior and how these CBCL/2 to 3, which took about for unaggressive conduct problems
circumstances may differ from the 10 minutes, she returned it to the versus aggressive conduct problems.
circumstances in which Mr. Stern receptionist, who took about 5 min- The physician, therefore, can see at
and others see Adam. The physician utes to score it by hand on the pro- a glance whether a child is deviant
then can decide among options, such file (Fig. 2). (The profile also could with respect to unaggressive delin-
as child-rearing advice for Ms. be scored by others, such as a cleri- quent behavior, aggressive behavior,
Stern, further evaluation of Adam, cal worker, nurse, or physician neither, or both. The profile dis-
or referral to a specialist. The cross- assistant, either by hand or by using played in Figure 3 was printed from
informant software described later a desktop or notebook computer, DOS software; Windows" versions
makes it easy for the physician to which would take about 2 minutes.) of the software were released in late
compare data obtained from differ- If the C-TRF had been mailed in by 1999.
ent informants about a child. Adams child care provider or pre-
school teacher, it also could be
scored on the C-TRF profile in The Youth Self-Report for
Obtaining and Scoring about 5 minutes by hand or in Ages 11 to 18 (YSR)
CBCL Data 2 minutes by computer. Hand- Adolescents such as Megan Dunn
There are several methods for scoring of the competencies on the can be asked to fill out the YSR to
obtaining and scoring CBCL data. CBCL/4 to 18 requires 5 to 7 minutes describe their own problems and

268 Pediatrics in Review Vol. 21 No. 1 August 2000

 CHILD DEVELOPMENT
Developmental Assessment

competencies. As with the other

TABLE 1. Forms Most Likely to be Used by assessments, the YSR can be filled
Medical Practitioners out in the waiting room and either
NAME OF FORM FILLED OUT BY hand-scored or computer-scored by
receptionists, clerical workers,
Child Behavior Checklist for Ages 2 to 3 Parents nurses, or physician assistants. The
(CBCL/2-3) physician then can view the scored
profile before seeing the adolescent.
Caregiver-Teacher Report Form for Ages Child care providers and If an adolescents reading skills are
2 to 5 (C-TRF) preschool teachers in doubt, the YSR can be adminis-
Child Behavior Checklist for Ages 4 to 18 Parents tered by a receptionist using the pro-
(CBCL/418) cedure described earlier for adminis-
tering the CBCL to parents whose
Teachers Report Form for Ages 5 to 18 Teachers reading skills are questionable.
(TRF)
Youth Self-Report for Ages 11 to 18 Youths The Teachers Report Form
(YSR) for Ages 5 to 18 (TRF)
For children who attend school, the
TRF completed by a childs teacher
TABLE 2. Commonly Asked Questions also can be hand-scored or
1. Who fills out the forms? computer-scored on a profile. The
Parents fill out CBCL, youths fill out YSR, teachers fill out TRF, scores obtained from one or more
caregivers and preschool teachers fill out C-TRF teachers can be compared with those
obtained on the CBCL/4 to 18 from
2. Who scores the forms? one or both parents or surrogates.
Clerical worker, receptionist, nurse, or physician assistant For 11- to 18-year-olds, the profile
3. How long does it take to score a form? scored from self-reports on the YSR
2 minutes by computer; 5 to 12 minutes by hand also can be compared with the TRF
4. What does the physician get? and CBCL profiles.
A profile that compares the child with a normative sample of
peers on each syndrome (eg, aggressive behavior, attention Cross-Informant
problems, somatic complaints) plus scores on each specific Comparisons of Parent,
problem Teacher, and Self-Reports
5. How long does it take the physician to evaluate a profile? Comparisons of parents reports
1 to 2 minutes with reports by others, such as
6. How much do forms cost? teachers and adolescents, are espe-
40 per CBCL, YSR, and TRF ($10 per package of 25) cially helpful for assessing the
40 per hand-scored profile ($10 per package of 25; not needed cross-informant consistency of prob-
if scoring software is used) lems on syndromes such as anxious/
depressed, somatic complaints, and
7. What software is available? attention problems to document the
DOS software is available for scoring all forms

Windows"95/98/NT software was released in 1999

need for further medical assessment
or referral for mental health ser-
8. Are there faster ways to process the data in busy practices? vices. To facilitate comparisons
Scannable bubble forms of the CBCL/4-18, YSR, and TRF can among scores from multiple infor-
be processed by reflective-read scanners, image scanners, and fax mants, cross-informant software
A client-entry program enables parents and youths to enter their enables users to enter data from
responses into a computer each CBCL/4 to 18, TRF, and YSR
9. Have these forms been well researched? scored for the same child. The soft-
A Bibliography of Published Studies3 lists more than 3,500 reports ware then produces a profile scored
of findings obtained with the CBCL and related forms from each form and side-by-side
comparisons of the scores obtained
10. Where can ordering information be obtained? from each informant on each item
Child Behavior Checklist and each syndrome. This enables the
University Medical Education Associates user to identify specific problems
1 South Prospect St. and specific syndromes on which
Burlington, VT 05401-3456 multiple informants agree versus
Fax: 802-656-2602; Tel: 802-656-8313 those on which they disagree.
E-mail: Checklist@uvm.edu; Web: http://Checklist.uvm.edu As an example, side-by-side com-
parisons of problem items may

Pediatrics in Review Vol. 21 No. 1 August 2000 269

 CHILD DEVELOPMENT
Developmental Assessment

professionals to record observations

TABLE 3. Clinical Conditions For Which The Family of of childrens behavior in school
CBCL Forms Has Been Applied classrooms and other group settings.
Table 2 presents answers to ques-
Abdominal pain Human immunodeficiency virus
tions that physicians commonly ask
Abuse infection
about the forms that they are most
ADHD Language disorders
likely to use.
Aggression Lead toxicity
Anxiety Leukemia
Arthritis Magnetic resonance imaging Comparisons with Other
Asthma Meningitis Forms
Autism Mental retardation
Birth defects Neuropathology In addition to the family of forms
Brain damage Obesity described in this article, other forms
Burns Obsessive compulsive disorder are available for obtaining ratings of
Cancer Oppositional disorder childrens problems. Among the best
Cerebral palsy Pain known are those developed by
Cleft palate Post-traumatic stress disorder C. Keith Conners4 for obtaining par-
Crohn disease Prader-Willi syndrome ent and teacher ratings of attention
Cystic fibrosis Preterm birth problems and hyperactivity. Several
Depression Rheumatic disease scales scored from the Conners par-
Diabetes School refusal ent and teacher forms correlate sig-
Drug therapies Separation nificantly with scales scored from
Eating problems Short stature the CBCL/4 to 182 and TRF5. For
Encopresis Sickle cell anemia children suspected of having ADHD,
Enuresis Sleep disturbance the Conners forms frequently are
Epilepsy Spina bifida used in conjunction with the CBCL
Gender problems Stress and TRF. Whereas the Conners
Genetic factors Substance abuse forms focus mainly on attention
Headaches Suicide problems and hyperactivity, the
Hearing impairment Temperament CBCL and TRF can be used to
Heart disease Tourette syndrome determine the extent of a childs
Hemophilia Turner syndrome problems across a broad spectrum of
Hormones Williams syndrome syndromes.
When ADHD has been diag-
nosed, brief versions of the Conners
forms may be readministered at
reveal a youth reporting suicidal Overview intervals of approximately once
ideation and behavior on the YSR Table 1 summarizes the forms, age weekly to evaluate the short-term
that neither his parents nor teachers effects of interventions such as stim-
ranges, and informants that are most
report. This would indicate a possi- ulant medication. The CBCL and
relevant for assessment by primary
ble risk for suicide that was not evi- TRF can be used to evaluate the
care physicians. Related procedures
dent to the youths parents and effects of interventions for ADHD
teachers. In another case, the side- are available for more specialized across broader ranges of functioning
by-side comparisons of syndrome assessments, including the Semi- assessed over longer periods. To
scores might reveal high scores on structured Clinical Interview for take into account the distinction that
the attention problems scale by all Children and Adolescents (SCICA)1 DSM-IV makes between inattentive
informants, which would support the and the Direct Observation Form and hyperactive-impulsive subtypes
need for treatment. (DOF)2, which can be used by para- of ADHD, separate scores can be

FIGURE 4. Flow chart of typical use of the CBCL in primary care.

270 Pediatrics in Review Vol. 21 No. 1 August 2000

 CHILD DEVELOPMENT
Developmental Assessment

computed for inattention and cal staff, it can be used routinely to

hyperactivity-impulsivity subscales assess most children. The physician PIR QUIZ
of the TRF attention problems scale. then can decide whether to review Quiz also available online at
Scores for these subscales are pro- the scored profiles for all cases. www.pedsinreview.org.
vided by the 1999 Windows" soft- Alternatively, the physician can
5. A true statement about the interpre-
ware for the TRF and can be review only the scored profiles on tation of the CBCL is that:
obtained by hand-scoring the TRF. which the staff member scoring the A. A score below the lower broken
Space limitations preclude sys- profile notes scores that are deviant line is within the normal range.
tematic comparisons of the CBCL or parents express concern about B. A score between the broken
family of forms with other forms for their child. The physician typically lines is clinically significant and
requires immediate intervention.
rating childrens functioning, but can review a profile in 1 to 2 minutes. C. A score that falls on the 75th
some distinctive features of the In all cases, the completed CBCL percentile for aggression indi-
CBCL and its related forms include: and profile can be retained in the cates that 75% of children
childs record to document his or tested demonstrate aggressive
1. Diverse behavioral/emotional her current functioning, as reported behaviors that are deviant.
problems and competencies are D. Arbitrarily setting lower
by the parent who completed the cutpoints for scores is not
assessed on parallel forms com- CBCL. If the physician elects inter- recommended and invalidates
pleted by parents, teachers, child ventions or referrals, the CBCL can the tool.
care providers, and youths. help to document the basis for these E. Scores must reach the cutpoint
Related forms are available for decisions. If no action is needed, the before they indicate a need for
completion by clinical interview- further evaluation.
CBCL provides a baseline picture of 6. A true statement about using the
ers and by observers who rate the childs functioning for compari- CBCL in a clinical setting is that:
childrens behavior in group set- son with CBCLs obtained later. Fig- A. A profile documenting deviance
tings such as classrooms. ure 4 outlines the typical use of the is helpful in supporting a need
2. The forms are scored on profiles CBCL in primary care settings. For for further evaluation.
that display syndromes derived B. Although available, the self-
further illustrations of applications to report version for completion by
from multivariate statistical anal- primary care, the Medical Practi- older children who can read is
yses of large samples of clini- tioners Guide for the Child Behavior not very reliable and, therefore,
cally referred children. Checklist and Related Forms7 can be is not recommended.
3. The syndromes reflect actual pat- ordered by mail, phone, fax, or online C. Software for computer scoring
terns of problems found among is not yet available.
(see Table 2 for address, phone and D. One form is applicable for all
clinically referred children, rather fax numbers, e-mail, and Web site). age groups.
than being based on a priori cri- E. Using input from more than one
teria, such as those of DSM-IV. source (eg, mother, father, child,
4. The profiles show how a childs teacher, or child care provider)
scores on each syndrome com- REFERENCES usually invalidates the tool.
7. Cross-informant comparisons of
pare with scores obtained from 1. McConaughy SH, Achenbach TM. Manual parent, teacher/child care provider,
national normative samples of for the Semistructured Clinical Interview and self-reporting:
for Children and Adolescents. Burlington,
children of the childs gender and Vt: University of Vermont, Department of A. Are cumbersome and difficult
age, as rated by the relevant type Psychiatry; 1994 to incorporate into a busy
of informant. 2. Achenbach TM. Manual for the Child general pediatric practice.
Behavior Checklist/4 18 and 1991 Profile. B. Are supported by computer soft-
5. Manuals for the forms display ware in older age groups only.
prevalence rates for each problem Burlington, Vt: University of Vermont,
Department of Psychiatry; 1991 C. Can be printed as comparison
plus the distributions of scores 3. Vignoe D, Berube RL, Achenbach TM. graphs illustrating results from
for all scales for children of each Bibliography of Published Studies Using the various sources.
gender and age. the Child Behavior Checklist and Related D. Rarely provide useful informa-
Materials: 1999 Edition. Burlington, Vt: tion.
6. More than 3,500 publications E. Serve primarily to evaluate
University of Vermont, Department of
report clinical, developmental, Psychiatry; 1999 whether mother and father have
genetic, prognostic, and other cor- 4. Conners K. Conners Rating Scales Man- similar or disparate child-rearing
relates of the syndromes found in ual. North Tonawanda, NY: Multi-Health philosophies.
8. The primary difference between the
studies performed in 50 cultures.3,6 Systems; 1990
CBCL and the Conners Rating
7. At least five studies have been 5. Achenbach TM. Manual for the Teachers
Report Form and 1991 Profile. Burlington, Scales is that the CBCL:
published on applications of the Vt: University of Vermont, Department of A. Addresses a broader scope of
forms to each of the topics of Psychiatry; 1991 behavior characteristics.
potential interest to physicians 6. Achenbach TM, McConaughy SH. Empiri- B. Cannot be used to evaluate the
shown in Table 3.3 cally Based Assessment of Child and Ado- effects of medications or
lescent Psychopathology: Practical Appli- behavior interventions.
cations. 2nd ed. Thousand Oaks, Calif: C. Has been used only to evaluate
Sage; 1997 children in North America.
Typical Use of the CBCL in 7. Achenbach TM, Ruffle TM. Medical D. Is not applicable to school-age
Primary Care Practitioners Guide for the Child Behav- children.
ior Checklist and Related Forms. Burling- E. Should not be used in conjunc-
Because the CBCL costs only ton, Vt: University of Vermont, Depart- tion with other surveys.
40 cents and can be scored by cleri- ment of Psychiatry; 1998

Pediatrics in Review Vol. 21 No. 1 August 2000 271