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

• 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

• 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

• 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

• 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

• 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

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

• 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

CBCL Broad Band Scale Scores
75
70
65 p<.001
p<.05
60
55
50
Internalizing Externalizing Total Problems
ARND (n=29) ADHD (n=30)

Cases with Elevated CBCL Broad-band Scales
60
50
40
30
20
10
0
100
90
80
70
(a) T-score > 63 p<.005
Internalizing p<.05
Externalizing Total
100
90
80
70
60
50
40
30
20
10
0
(b) T-score>70
P<.05
P<.05
ARND ADHD
P<.10

CBCL Narrow-band Scale Scores
75
70
65 p<.05
60 p<.01
p<.001
55
50
AnxDepr WithdDepr Somatic SocialProb ThoughtProb AttnProb RuleBreaking Aggressive
ARND (n=48) ADHD (n=48)

Individual Items on Rule-Breaking Scale p<.001
50
40
30
20
10
100
90
80
70
60 p<.05
0
Ac tsY ou ng
Ar gu es
Ca n' tC on ce n
Re stl es s p<.001
Cr ue l
Di so be d
No
Gu ilt
ARND (n=48)
Im pu ls
ADHD (n=48)
Ly in g
Sh ow
Of f p<.05
St ea ls

90 p<.01
p<.05
70
60
50
40
30
20
10
0
AnxDepr WithdDepr
30
20
10
0
60
50
40
100
90
80
70
(b) T-score >70 p<.01
AnxDepr WithdDepr p<.05
Somatic p<.05
Somatic
SocialProb ThoughtProb AttnProb RuleBreaking Aggressive
SocialProb ThoughtProb
ARND (n=48) ADHD (n=48)
AttnProb p<.01
p<.10
RuleBreaking Aggressive

75
70 p<.01
Conner’s Parent Rating Scale (CPRS) Results for ARND and ADHD Groups p<.05
p<
.
05 p<
.
05
65 p<.01
60
55
50
Oppos CogProb Hyperact AnxShy Perfec SocProb Psychosom ADHDindex Restl/Imp EmotLab Global
ARND (n=35) ADHD (n=35)

CPRS DSM-IV ADHD Scales
70
65
60
80
75
55
50 p<.05
Inattent Hyper-Imp Total
ARND (n=35) ADHD (n=35)

65
60
55
75
70 p<
.
01
50
Oppositional
CPRS Scales Involving
Significant Group Differences p<
.
05
Hyperactive p<.01
p<
.
05
Psychosomatic Emotional Lability
ARND (n=35)
ADHD (n=35) p<
.
05
Global

Cases with Clinically Elevated (T>70)
CPRS Scores
70
60 p<.10
50 p<.10
40 p<.01
p<.10
30
20
10
0
O p p o s
C o g
P ro b
H yp er ac t
A n xS h y
P er fe c
S o cP ro b
P sy ch o so m
A
D
H
D in d ex
R es tl/
Im p
E m o tL ab
G lo b al
ARND (n=35) ADHD (n=35)

• 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

• 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

• 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