These results demonstrate that a deviant score on the CBCL-PTSP scale is a good marker for the profile of high attention problems, aggressive behavior, and anxious/depression that has been called the CBCL-DP. Coupled with the demonstration of Ayer et al. (2009)
that the CBCL-PTSP and the CBCL-DP scales can be explained by either two highly correlated latent variables or, more parsimoniously, by one underlying latent variable, the current results provide further convincing evidence that elevations on the CBCL-PTSP scale predict the same behaviors as the CBCL-DP profile. The finding of two classes that closely resemble the CBCL-DP may at first seem to raise questions about the specificity of the profile. However, it is clear that individuals in Class 6 are distinguished from individuals in Class 7 on the basis of different types of aggression – relational versus direct (or overt) (Crick & Grotpeter, 1995
). This distinction has been used to clarify that all aggression does not have to result in direct physical attacks on other individuals, but can include verbal, oppositional, and other relational behaviors. The items which distinguish Classes 6 and 7 in the current study are exactly the same items that emerged when our group performed a factor analysis of the aggression scale in a Dutch sample (Ligthart, Bartels, Hoekstra, Hudziak, & Boomsma, 2005
). In that work, sex differences were larger for direct aggression than for relational aggression. Consistent with this finding, the current study demonstrates that girls are more likely to be in the class with relational aggression (Class 7) while boys are more likely to be in the class that has both relational and direct aggression (Class 6, the DP Class). The CBCL-PTSP appears to be slightly more predictive of the DP Class than the DP Class without violence when overlapping items are removed, but remains highly predictive of both of these types of children with profound problems with dysregulation. What distinguishes the CBCL-DP from the CBCL-PTSP scale, therefore, is that the CBCL-DP also captures the three components of self-regulation separately and especially identifies those children with more direct aggression. The CBCL-PTSP, on the other hand, also identifies children in the CBCL-DP without direct aggression class until the overlapping items are removed.
This finding has important clinical implications for the children who have been identified with both the CBCL-DP profile and the CBCL-PTSP scale. As noted above, the CBCL-DP has been utilized mainly as a research tool to identify children with pediatric bipolar disorder (Faraone et al., 2005
). In contrast, the CBCL-PTSP scale has been hypothesized as a screening device for PTSD in children, or at least a measurement of the severity of symptoms in children with PTSD (Wolfe & Birt, 1997
). On the basis of these findings and earlier work (Ayer et al., 2009
), we would hypothesize that the reason for the high scores on the CBCL-PTSP in children with PTSD and the reason for the presence of the CBCL-DP profile in samples that have many broad phenotype pediatric bipolar children is because children with both these diagnoses have primary problems with self-regulatory behaviors. This is not to say that children with PTSD and bipolar disorder have the same disorder. Rather, that this scale and this profile can be used as an empirical measure of dysregulation, rather than being tied to specific disorders. Given these findings and previous work suggesting that many if not most children who score highly on the CBCL-PTSP scale do not have trauma histories, we recommend that the name of the CBCL-PTSP scale should be changed to the “CBCL-Dysregulation Short Scale” or CBCL-DSS in order to avoid the use of this scale as a diagnostic tool for PTSD. This recommendation comes from the evidence that the scale appears to function best as a marker of broad dysregulation that can be present in a range of diagnoses, including but not limited to PTSD and bipolar disorder. Further, we recommend this scale be used as a marker of dysregulation rather than to predict or track PTSD symptoms. Similarly, the use of the name CBCL-Dysregulation Profile should discourage the use of this profile to identify individuals with narrow phenotype pediatric bipolar disorder. It does not appear useful in that regard. It may, however, be useful in identifying children with a diagnosis being considered for DSM-V, namely “Temper Dysregulation Disorder with Dysphoria.” This proposed disorder is designed to identify children with severe mood problems but without narrow phenotype pediatric bipolar disorder. Whether the CBCL-DP identifies these children separately from children with other disorders is a topic for further research.
The renaming of a construct has diagnostic and treatment implications, particularly in this period in which the DSM-V is being prepared. Construction of reliable, empirically-based measures of poor self-regulation in children that can be measured across informants, across cultures, across ages, and across gender can inform the DSM revision process (Hudziak, Achenbach, Althoff, & Pine, 2007
). The identification here of both a short scale and a longer profile that can screen for “dysregulated” children should then be incorporated within a DSM framework. The idea of “dysregulation” as a construct worthy of identification on its own and without the encumbrance of being attached to other diagnoses bears consideration. The term “dysregulation” is often used clinically in a very general way to describe children who have problems controlling their behaviors, moods, and cognitions despite research demonstrating some separation of these domains (Fitzsimons & Bargh, 2004
). Because there has been no accepted “gold standard” for what a “dysregulated” child looks like, both the ability to describe these children clinically and the ability to research them as a group has been hindered. By describing these children with the most commonly used assessment device for child behavior problems, we hope to promote additional discussion and empirical investigation by scientists and practitioners about evidence-based assessment and identification of youth with core regulatory deficits. In our opinion, this profile and this scale appear to apply best as measures of disordered self-regulation with concomitant disturbance in the regulation of affect, behavior, and cognition. Thus, the proposal to name the profile of high attention problems, aggressive behavior, and anxious/depression the CBCL-DP reflects its composition of three empirically derived scales which each measure a component of self-regulatory behavior (attention problems = cognitive dysregulation, aggressive behavior = behavioral dysregulation, anxious/depression = affective dysregulation). Because the CBCL-PTSP measures these same children and the same latent construct, we recommend a befitting name.
This research has limitations. The most important limitation is that we have not measured other self-regulatory behaviors in this sample. Other ways to measure self-regulatory capacity include the use of emotional, attentional, and behavior regulation tasks in a sample with the CBCL-DP and/or CBCL-DSS to determine the degree to which these three components of self-regulation are impaired. Although Ayer and colleagues (2009)
demonstrated that the highest factor loadings on items loading onto the single dysregulation construct spanned all three dimensions, it will be necessary to conduct additional research to compare these CBCL scales to better-established measures of affective, attentional, and behavioral dysregulation. This research is underway. This study also did not specifically assess for trauma to provide a quantitative estimate of the number of children who score highly on the PTSP scale who do not have a documented trauma history. Further, LCA might not be easily applied in clinical practice. However, the concept behind it is easily implemented. Rather than concentrating only on elevations on individual subscales on the CBCL (or on any other instrument of child behavior for that matter), we recommend an examination of the pattern
of responding. If the child has elevations on attention problems, aggressive behavior, and anxious-depression in the borderline or clinical range, they would be considered to have this CBCL-DP profile. The LCA approach simply captures the child who has elevations in the clinical range on attention problems and aggressive behavior but who may have a T-score 1 unit below the cutpoint for anxious-depression. Rather than considering this child qualitatively different from the child who had exactly the same scores on attention problems and aggressive behavior but who was rated 1 point higher on anxious-depression, LCA would classify them together. We encourage this more dimensional approach to examining profiles of behavior (Hudziak et al., 2007
). We are further encouraged that future versions of the scoring algorithms for the CBCL may incorporate a return to a profile-based approach that were present in earlier versions of the CBCL (Achenbach, 1993
). This is an area of active research that we are performing with Dr. Achenbach and his team. Overall, these data provide evidence that two widely used scales that have been previously associated with specific diagnoses of PTSD and bipolar disorder, respectively, may be better conceptualized as measuring a single broad dysregulation disorder.