Rationale

CAREGIVER SCREENING FOR FASD USING THE CHILD BEHAVIOR CHECKLIST (CBCL) AND THE

CONNER’S PARENT RATING SCALE (CPRS)

ELLEN FANTUS, JOANNE ROVET, KELLY NASH, RACHEL GREENBAUM,DONNA SORBARA, IRENA NULMAN, GIDEON KOREN

The Hospital for Sick Children, Toronto

Rationale

• Cognitive problems extensively studied in children with FASD

• Behavioral sequelae less well studied in children with FASD

• FASD associated with high risk of mental health problems in adults

• Children with FASD often misdiagnosed with Attention Deficit Hyperactivity Disorder (ADHD)

• Therefore need to identify full spectrum of behavioural disorders in children with FASD

Rationale (cont’d)

• Caregiver questionnaires provide useful information on behavioural characteristics of children with disorders

• Several studies using caregiver questionnaires with FASD have provided inconsistent results

Past Studies• Steinhausen et al (1993)

– CBCL to FAS adolescents– Elevated scores on hyperactivity and anxiety but not aggression or

delinquency scales• Roebuck et al (1999)

– Personality Inventory for Children (PIC) to FAS/ARND and control children – Elevated scores on scales of delinquency, psychosis, emotional lability, social

withdrawal, and social problems• Mattson et al (2000)

– CBCL to FAS/ARND children– Elevated scores on aggression, delinquency, social, thought, and attention

problems• Greenbaum et al (2004; Greenbaum, 1999)

– CBCL to FASD and matched control children– FASD higher incidence of clinically elevated externalizing behaviour problems

with clinically elevated scores on attention, thought processing, social functioning, delinquency, and aggression scales

Motherisk Follow-up Clinic• Founded in 1996• Over 200 children (aged 3-17) with known

and suspected alcohol exposure have received a comprehensive neuropsychological and medical evaluation

• FASD diagnosis provided when indicated• Ongoing data base of results to identify

behavioural phenotype in FASD

Early Results• Preliminary data analysis on children

assessed from November 1998 to September 2002 revealed significant findings on 2 caregiver questionnaires

• On CBCL, most children showed clinical elevations on attention problems, delinquency, and aggression scales

• On CPRS, most children met criteria for DSM-IV diagnosis for ADHD

OBJECTIVES

• To compare FASD with ADHD

• To compare and contrast results from CBCL and CPRS

• To identify the behavioural phenotype in FASD

• To determine utility of these questionnaires in telehealth diagnosis

DESIGN

• Matched pairs analysis of ARND and ADHD on CBCL and CPRS

TEST MEASURES

Participants

• CBCL– 48 ARND/ADHD pairs

matched for age and sex

– 7-11 years of age– ADHD from 3 studies

in Rovet lab in same time period

• Conners– 35 ARND/ADHD pairs

matched for age, sex, and socioeconomic status (SES)

– 7-11 years of age– ADHD from 2 studies

in Rovet lab in same time period

50

55

60

65

70

75

T-S

co

re

Internalizing Externalizing Total Problems

ARND (n=29) ADHD (n=30)

p<.001p<.05

CBCL Broad Band Scale Scores

Cases with Elevated CBCL Broad-band Scales

0

10

20

30

40

50

60

70

80

90

100

Pro

po

rtio

n o

f C

as

es

in

Gro

up

Internalizing Externalizing Total

p<.005p<.05

(a) T-score > 63

0

10

20

30

40

50

60

70

80

90

100

Pro

po

rtio

n o

f C

as

es

in

Gro

up

ARND ADHD

(b) T-score>70

P<.05

P<.05 P<.10

50

55

60

65

70

75

T Sco

re (M

n=50

;SD=

10)

AnxDepr WithdDepr Somatic SocialProb ThoughtProb AttnProb RuleBreaking Aggressive


p<.01

p<.05

p<.001

CBCL Narrow-band Scale Scores

0

10

20

30

40

50

60

70

80

90

100

Pe

rc

en

t o

f G

ro

up


p<.001

p<.05

p<.05

Individual Items on Rule-Breaking Scale

p<.001

0

10

20

30

40

50

60

70

80

90

100Pr

opor

tion

of C

ases

in

Grou

p


p<.05

Cases with Elevated CBCL Narrow-band Scales

p<.05p<.01

0

10

20

30

40

50

60

70

80

90

100

Pro

po

rtio

n o

f C

ases

in

Gro

up



p<.05

p<.01 p<.10

p<.01

(a) T-score >63

(b) T-score >70

50

55

60

65

70

75

T Sc

ore (

Mn=5

0;SD

=10)

Oppos CogProb Hyperact AnxShy Perfec SocProb Psychosom ADHDindex Restl/Imp EmotLab Global


p<.01 p<.05

p<.01

p<.05

Conner’s Parent Rating Scale (CPRS) Results for ARND and ADHD Groups

p<.05

50

55

60

65

70

75

80

T S

core

(M

=50

;SD

=10

)

Inattent Hyper-Imp Total


p<.05

CPRS DSM-IV ADHD Scales

50

55

60

65

70

75

T S

core

(Mn

=50;

SD

=10)

Oppositional Hyperactive Psychosomatic Emotional Lability Global

ARND (n=35)ADHD (n=35)

CPRS Scales Involving Significant Group Differences

p<.01

p<.05 p<.05

p<.05

p<.01

0

10

20

30

40

50

60

70Pe

rcen

t of g

roup


Cases with Clinically Elevated (T>70) CPRS Scores

p<.10p<.01

p<.10

p<.10

Summary of Findings• FASD distinct from and more severely affected than

ADHD• On CBCL, FASD have more externalizing problems

(rule breaking, social problems,aggressive), whereas ADHD have more somatic complaints and more internalizing problems

• CBCL item analysis showed FASD highly likely to be cruel, lack guilt, steal, lie, and act young

• On CPRS, FASD more oppositional, hyperactive, impulsive, emotionally labile whereas ADHD more psychosomatic and have more internalizing problems

Conclusion

• Caregiver questionnaires can be used as a screening tool to identify children with FASD

• Identification of high risk cases in remote locations can lead to primary interventions

• Early intervention may circumvent secondary disabilities in underserviced areas.

• Treatment programs to address their specific needs

Future Directions

• Need to develop targeted treatment programs to deal with their specific needs within their community

• Need further research comparing with other psychiatric populations e.g., ODD/CD

• Need to disentangle effects of alcohol from genetic psychiatric susceptibility and environmental factors

Rationale

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