Running head: OCD screening with CBCL
This is the author’s final draft post-refereeing article published in
Journal of Anxiety Disorders. 2008 Oct;22(7);1172-9.
Ivarsson T, Larsson B.
The Obsessive Compulsive (OCS) Scale of the Child Behavior Checklist : a comparison between Swedish
children with Obsessive-Compulsive Disorder from a specialized unit, regular outpatients and a school
For publishers version: http://dx.doi.org/10.1016/j.janxdis.2007.12.004
The Obsessive Compulsive Symptom (OCS) Scale of the Child Behavior Checklist:
a comparison between Swedish children with Obsessive-Compulsive Disorder from a
specialized unit, regular outpatients and a school sample
Tord Ivarsson MD1
Bo Larsson MD, 2
1Centre for Child and Adolescent Mental Health, Eastern and Southern Norway Gullhaug
Torg 4B, 0484 Oslo; Postal address: Postboks 4623 Nydalen, 0405 Oslo, Norway;
Department of Child and Adolescent Psychiatry, Göteborg University, Kungsgatan 12, SE-
411 19 Göteborg, Sweden
2Regional Centre of Child & Adolescent Mental Health, Department of Neuroscience,
NTNU, MTFS N-7489, Trondheim, Norway
Correspondence: Tord Ivarsson Centre for Child and Adolescent Mental Health, Eastern
and Southern Norway Gullhaug Torg 4B, 0484 Oslo; Postal address: Postboks 4623
Nydalen, 0405 Oslo, Norway
Keywords: Obsessive-Compulsive Disorder; Child Behavior Checklist; school sample;
child psychiatric clinic; parent report.
To evaluate the discriminative power of various items as reported by parents in the
OCS-scale extracted from the Child Behavior Checklist (CBCL) problem scale and to
compare findings with outcomes of previous validation studies.
Children referred to a specialized child psychiatric Obsessive-Compulsive Disorder
(OCD) clinic (OCD group)(n=185) receiving a formal OCD diagnosis according to DSM
IV criteria based on interviews with the Children’s Yale-Brown Obsessive Compulsive
Scale (CY-BOCS) were compared to a sample recruited from regular child and adolescent
psychiatric outpatient clinics (CPO group) (n=177). Both samples were compared to a
normative school sample (SS group) and all three groups were matched for age and gender.
Thirty seven CBCL items, mostly representing core internalizing symptoms and parts of
the thought problem scale as well as physical and sleep problems, were first identified. Ten
of these items (including all discriminative items in previous validation studies) could
distinguish children with OCD from CPO patients. In a subsequent analysis, the results of a
logistic regression showed that four CBCL items, “Obsessions,” “Fearful and Anxious,”
“Compulsions,” and ”Worries” remained significant predictors. These four OCS items and
previous used CBCL OCS-scales were further examined by means of ROC-analysis
showing that the “Obsessions” and “Compulsions” CBCL items were the strongest
These two CBCL items performed well as screens for OCS symptoms in children and
adolescents and the addition of similar CBCL items did not further increase sensitivity or
specificity. It is suggested that parental responses on these two items could preferably be
used as screen for OCD in children and adolescents in regular child psychiatric clinics.
Although obsessions and compulsions are infrequent among children and adolescents in
the general population, they are more prevalent than commonly anticipated. In a recent
epidemiological survey about 0.5% of the children had clinical levels of OCD symptoms
(Heyman et al., 2001), while other studies have indicated higher prevalence rates ranging
from 1.5% to 3% (Flament et al., 1989; Valleni-Basile et al., 1994). Although these
problems are likely to be much more common in clinical settings, one survey did not find a
single OCD case in Child and Adolescent Psychiatry (CAP) outpatient units (Staller,
2006). Another survey from four different CAP units in Germany and Switzerland reported
OCD diagnoses in 0.7-1.2% of the patients (Dopfner et al., 1997), i.e., identical or slightly
higher prevalence rates to those reported for children in the general population.
An important task for clinicians is to diagnose OCD correctly although the disorder
itself can impersonate many other symptoms in other psychiatric disorders (OCD has more
than 60 specific obsessions and compulsions, many of which resemble other psycho-
pathological symptoms) (Hanna, 1995; Rapoport, 1989). Many patients are also secretive
about the sometimes bizarre and mostly irrational nature of their symptoms often believing
that others will regard them as mad and experience feelings of shame. The possibility of
non-identification of children suffering from OCD is therefore apparent.
A further diagnostic problem is due to the fact that about three quarters of OCD
patients also report presence of other comorbid symptoms (Hanna, 1995; Geller et al.,
2000; Ivarsson et al., 2007). So, the practitioner might meet with a patient who actively
hides his/her irrational OCD-symptoms, while being more forthcoming with depressive
symptoms that appear to be more acceptable as the presenting problem.
A possible option for a busy practitioner is to utilize a screening measure filled out by
the patient or parent before consultation. In a few validation studies (Geller et al., 2006;
Hudziak et al., 2006; Storch et al., 2006), the widely used Child Behavior Checklist
(CBCL) developed by Achenbach (1991), has been found to be able to identify obsessive-
compulsive symptoms in children and adolescents as rated by parents. In the CBCL, a
specific scale, the Obsessive-Compulsive Scale (OCS) (Nelson et al., 2001), has been
extracted and found to be both reliable and valid. Nelson (2001) extracted eleven CBCL
items “that were hypothesized to be the most pertinent to the diagnosis of OCD,” mostly
from the “Thought-problems” and the “Anxious/Depressed” sub-scales as they had shown
elevated scores in patients with OCD in previous research (Hanna, 1995). Using factor
analysis, eight of the eleven items could be shown to represent an OCD-scale with good
internal consistency, and also proved to be able to differentiate between OCD-patients
from those with other psychiatric disorders and from adolescents in the general population.
The aims of the present study were to extend and further validate outcomes of previous
studies of the OCS scale of the CBCL in a different population and country (Sweden). The
study also set out to examine whether the previously used OCS scale(s) (i.e., those of
(Nelson et al., 2001; Geller et al., 2006) are optimal, or whether other symptom
constellations would perform better.
The Obsessive-Compulsive Disorder (OCD) group. This sample included 185 children
(12 years or younger) and adolescents (13 years or older) (91 boys and 94 girls: age range
4-17) from two clinic samples in Gothenburg. The first one was gathered from an
outpatient clinic housing an OCD-project starting in 1991 (n=86: girls/boys: 35/51;
children/adolescents: 27/59). The second sample included all patients that were assessed
and treated at a specialized OCD-unit starting in 2001 (n=99: girls/boys: 59/40;
children/adolescents: 29/70). The two groups differed with regard to co-morbidity in that
non-specialized group had more patients without co-morbid diagnoses (46.5%) as
compared with the specialized group (20.4%), a statistically significant difference ( p<
.0001). However, this is probably an artifact of the diagnostic assessment procedure for
other diagnoses which for the non-specialized group was a clinical interview supported by
self- and parental rating scales (among others, the CBCL) while the specialized groups was
interviewed using the KSADS (Kaufman et al., 2000). Major co-morbidities like the
Tourette’s syndrome (28% versus 19%, n.s.), Major Depression (15% versus 15%, n.s.)
and ADHD (11% versus 12%) differed less while for example Oppositional Defiant
disorder (0 versus 9%, (p< .003) differed more, however the gender and age differences
across the groups had no influence.
Most patients had intact families (70.4%) with Swedish ethnicity; 7% were living with one
parent and 12% had both parents of non-Swedish ethnicity. The socio-economic status of
our families did not differ between the two samples, both being close to the mean SES in a
recent study sample from the general population (Ivarsson, 2006). Thirty-eight outpatients
did not fulfill the diagnostic criteria for OCD, and an additional 19 individuals (7 girls and
12 boys) who were eligible for the study, declined to participate.
The child psychiatric outpatient group (CPO). This sample consisted of 177 subjects
(girls/boys: 78/99; children/adolescents: 111/66; age range 7-16) who were referred to four
regular outpatient clinics in central Sweden. The problem assessment was based on
medical records and somewhat more than one in four asked for consultation for
externalizing problems, somewhat less than one in four for internalizing problems and
slightly less than one out of five for crises and conflicts within the family, a significant
problem in many of these families according to an assessment of the “family emotional
climate” (Nyberg et al., 2001). This is roughly in line with the CBCL data that indicate that
somewhat less than 1/3 had Internalizing scores above the 95:th percentile in the normal
group (score of 15 or above). However, significant externalizing symptoms (score of 16 or
above that are found in less than 5% of the normal group) were present in 44% of these
juveniles. Other problems, e.g., Attention problems were even more common (48% scored
above 95th percentile), as might be expected from a general child psychiatric sample. As
the assessment procedure was not based on (semi)structured interviews, we cannot give
precise figures for any diagnoses, e.g., OCD (Nyberg et al., 2001). However, it seems
probable (from the CBCL data) that OCD might have been present in a small minority of
the cases (probably not less than three individuals and not more than 6 individuals), i.e., at
comparable rates reported by Doepfner at al (1997).
School Sample (SS). This sample was selected from a school-based population study of
children and adolescents aged 6-16 years (Larsson & Frisk, 1999). In the present study,
subjects were randomly selected from this sample to equal the size of the two clinic
groups. The distribution of sex and age of the final SS group consisting of 317 subjects
(girls/boys: 147/170; children/adolescents: 120/197) was not statistically different from the
OCD group. However, it differed from the CPO group in that children in the CPO group
were significantly (M=10.4 versus M=12.4; t(307.3)=-7.0, p= .0001) younger than those in
the SS group, especially the boys.
Child Behavior Checklist (CBCL). A Swedish version of the 1991 version of the
CBCL was used for parents to assess emotional and behavioral problems among the
children (Achenbach, 1991; Larsson & Frisk, 1999). It consists of two parts one addressing
social competence and the other for assessing emotional and behavioral problems in
children aged 4 to 18 years. In the study, only the latter part was used consisting of 118
problem items rated on a three-point scale: 0 =”Not true”; 1 =”Somewhat or sometimes
true”; 2 =”Very true or often true”. Parents are asked to rate current problems in the child
or occurring in the last six months. Two broad-band dimensions, internalizing and
externalizing syndromes can be formed. The internalizing broad-band syndrome consists
of three narrow-band syndromes: Withdrawn, Somatic complaints and Anxious/depressed,
and the broad-band externalizing syndrome includes the Aggression and Delinquent
problem scales. In addition, Social, Thought, and Attention problem scales can be formed.
Total scores range between 0 and 226.
In a review, Achenbach (2002) concluded that the CBCL has proved useful for various
purposes. Although the 1991 version of the CBCL was used in the present study, several
new items in the most recent version of the CBCL have replaced about a third of the older
OCD items (Achenbach & Rescorla, 2001).
Children’s Yale-Brown Obsessive Compulsive Scale (CYBOCS). This is a semi-
structured interview containing questions regarding obsessions and compulsions in the
child. Scale scores for severity of obsessions and compulsions (range: 0-20) are added to
form a total score (range: 0-40). Further, lack of insight, avoidance, indecisiveness, inertia
and pathological doubt can be gauged with scores ranging from 0 to 4. Finally, based on all
information gathered during the interview a global severity score is assigned. The
checklists and the severity ratings were based on interviews with each child and
The first author diagnosed all patients with OCD in accordance with the DSM-IV
criteria (American Psychiatric Association, 1994) based on all information gathered during
the diagnostic work-up including the CYBOCS interviews.
The study group participants were included in the study after informed consent from
the parents. The ethics committee of the Medical faculty in Gothenburg approved of the
Chi-square test was used to analyze associations between various CBCL items and the
three samples. Items emerging as significant in bivariate analyses were further examined in
regard to predictive power using logistic regression analysis with clinical status (OCD
versus non-OCD) as dependent variable and back wise elimination of predictors (table 3).
Receiver operating curves (ROC) were used to estimate optimal sensitivity and
specificity of various models including the various sets of CBCL items.
Insert table 1 about here
In a first analysis, the discriminative power of the OCS scale to distinguish OCD
patients from children and adolescents in the SS group was examined. Results showed that
thirty seven CBCL items most strongly associated with group condition could be identified
(see table 1). In a second step, the discriminative power of these items to distinguish OCD
patients from those in the CPO group was examined (see table 1).
Eleven CBCL items could distinguish OCD patients both from children and
adolescents in the SS sample and from those in the CPO group, eight out of them being
included in the Nelson OCS scale (table 1). However, another three items, out of which
one, “Fearful and anxious” is closely related to anxiety disorder in general, one “Too
cleanly and orderly” is OCD-like, and a third item “Depressed” were also significantly
associated with OCD. However, the item “Too cleanly and orderly” was excluded in the
analysis because its phrasing had been changed in the 2001 revision of the CBCL.
In subsequent logistic regression analysis, the power of the significant predictors
obtained in the bivariate analyses was further examined (see table 2).
Insert table 2 about here
Overall, these four items could correctly classify 90.3% of all the patients with a
sensitivity of 85.8 and a specificity of 94%. This significant model, Chi2 (df 4)=269.6, p<
.001, explained 78% of the variance (Nagelkerke R2).
Using these variables in an OCS-scale (LogRegOCS) construed in the present study by
multiplying the scores of each patient with the B-value and summarizing these scores,
comparisons were made with the Geller OCS (Obsessions and Compulsions)(Geller et al.,
2006) and the Nelson OCS (Obsessions, Compulsions, Fears think or do something bad,
Thinks s/he must be perfect, Feels too guilty, Worries, Strange behaviors, Strange ideas)
(Nelson et al., 2001) by means of ROC curves. The results indicated that the more
complicated scales had little advantage over the Geller OCS scale only including the
obsession and the compulsion items (see figure 1 and table 3)
Insert Figure 1 and Table 3 about here
As table 3 shows, the scales had very similar areas under the curve supporting the
validity of the Geller OCS items also in this data set. Adding more items would decrease
specificity as well as sensitivity although the differences were marginal. Using the short
Geller OCS-scale with a cut-off of > 3 points leads to a sensitivity of .79 and a specificity
of .96 with a positive predictive (PP) value of 0.96 and a negative predictive value (NP) of
.82. The LogReg OCS-scale could be used with a cut-off score of 1.7 leading to a
sensitivity of .91, a specificity of .89, with a PP value of .88 and a NP of .92. Finally, using
the Nelson OCS-scale in a Swedish population with a cut-off score of 4.5 would lead to a
sensitivity of .89 and a specificity of .77 with a PP of .78 and a NP of .88.
In the present study, the discriminative power of parent reports of various items in the
OCS-scale extracted from the Child Behavior Checklist (CBCL) problem scale was
examined and compared to findings of previous studies conducted in the USA. The present
study compared outpatient children referred to a specialized OCD clinic with those in
regular child psychiatric clinics, both samples contrasted with a normative sample of
Overall, our results were strikingly similar to those reported by Geller (2006), who
proposed that parental reports on two specific OCD questions of the CBCL, i.e., the
presence of obsessions and compulsions, might be sufficient to screen for OCD in school-
aged children. Use of a more complicated OCS scale and the addition of more CBCL items
seems to improve the validity only marginally (Nelson et al., 2001; Hudziak et al., 2006;
Geller et al., 2006; Storch et al., 2006).
Stepwise sorting of the CBCL items should ensure that item selection was based on
solid empirical rather than a priori grounds. The results of our logistic regression also
produced an optimal and economical measure including as few items as possible. This
analysis indicated that out of the ten items chosen for further analysis; only four of those
extracted in the original Nelson OC-scale are needed. Further, the results of our analysis
showed that one CBCL-item “Fearful and Anxious” was a negative predictor of an OCD
diagnosis. Possibly, this item covers more “classical” anxiety symptoms related to social
phobia, school phobia and generalized anxiety.
Overall, our results indicated that parental reports on the CBCL may serve as a
valuable screening tool as it covers a wide range of emotional and behavioral problems in
the child. In this respect, the CBCL is preferable and easy to use as a screen for OCD in
children and adolescents but also provides important and broad-based information on
potential comorbid problems or symptoms.
However, in the interpretations and the practical use of our findings, the following
limitations should be considered. Perhaps, the most serious challenge to our main result
supporting the use and power of the simple Geller OC-scale depends on the settings in
which our study samples were recruited. Parents of OCD-patients seeking help at a
secondary unit specializing in the management of children and adolescents with OCD, are
likely to already have identified the prime psychiatric problems in their children as OCD.
Therefore, we cannot generalize our results to settings in non-specialized CAP-clinics,
where parents might not yet have identified the child problem as having OCD. Even if they
have observed typical obsessive-compulsive phenomena in the child, it is not certain that
parents would find the specific OCD-items in the CBCL as correctly describing their child.
Secondly, no specific diagnostic information on child OCD was available for our regular
clinical outpatients and therefore a few patients with a formal OCD diagnosis might have
been included. However, this potential bias is likely to underestimate the psychometric
properties of the OCS scales, and our results are also very similar to those reported by
other investigators and similar comparative studies (Nelson et al., 2001; Hudziak et al.,
2006; Storch et al., 2006).
Limitations of the present study should caution the use of a cut down Geller OC-scale
as a screen in non-specialized CAP-clinics. In such settings, either the original Nelson OC-
scale or our LogRegOCS-scale is likely to perform better in terms of sensitivity. Using
these scales with the recommended cut-off scores should be a valuable screening tool for
OCD in regular child psychiatric service.
Somewhat surprisingly, our findings also showed that the Hoarding item of the CBCL
was not helpful in the diagnosis of OCD in school-aged children. Although the item “Too
cleanly and orderly” was identified in the first two steps as a powerful discriminator, it was
replaced in the new CBCL version and could therefore not be included in our logistic
regression or ROC analysis.
While extensive diagnostic information was gathered for our OCD-patients, we did not
have access to such information for the regular child psychiatric outpatients, nor for the
The CBCL is a valuable tool in the assessment of various emotional and behavioral
problems in child and adolescent psychiatric populations, and its versatility extends its use
also to identify children with less common psychiatric problems such as OCD. The
outcomes of the present and previous validation studies indicate that two specific CBCL
items, i.e. obsessions and compulsions in the child as reported by parents, were sensitive
and specific discriminators. These two items alone or together with the other six items in
the Nelson OC scale, or the two items in our LogReg OCS-scale, should work well in
regular clinical settings as a screen for obsessive-compulsive symptoms in children and
CBCL items distinguishing between OCD-patients and those in the CPO group as
compared to those in the SS group. The number in the cells denotes percentages.
Results of chi-square analysis with p-values.
1 32.6 18.6 1 34.5
2 24.3 3.5
1 8.4 2.9 1 13.6
2 84.3 1.0
1 33.2 4.1 1 24.9 Clinging or too
2 6.5 0.6
1 35.3 10.5 1 32.4
2 9.8 2.2
1 32.1 1.9 1 25.6
2 4.9 0.6
1 31.0 3.5 1 25.4
Cries a lot
2 6.0 0.6
1 42.4 17.1 1 39.0 Demands a lot of
2 25.0 4.4
1 27.9 16.2 1 15.9 Fears animals,
2 21.8 2.9
1 16.3 1.3 1 13.6
Fears go to school
2 6.0 0.0
1 35.7 24.5 1 34.1 Fears to think or do
2 36.3 3.5
1 31.9 24.4 1 27.8 Thinks s/he must
2 33.5 4.4
1 34.2 8.7 1 38.4 Feels nobody likes
2 14.7 1.0
1 39.6 9.9 1 34.1
2 18.7 1.0
1 45.1 9.2 1 39.2
Nervous and tense
2 24.7 0.6
1 15.5 1.0 1 10.2 Nervous
2 12.2 0.3
1 35.7 11.1 1 33.3
2 5.5 1.3
1 45.3 8.5 1 31.3
Fearful and anxious
2 27.6 0.3
1 19.7 5.1 1 11.3
2 9.8 0.0
1 38.3 4.5 1 18.3 Too strong guilt
2 19.4 0.6
1 32.1 6.3 1 16.9
2 10.9 1.3
1 23.0 3.7 1 11.6 Physical spts: body
2 8.0 1.0
1 19.3 1.3 1 5.1
2 64.8 0.6
1 12.7 14.1 1 14.1 Hoards objects (of
2 3.2 10.3
1 22.4 1.3 1 5.7
2 24.1 0
1 19.2 1.9 1 3.5
2 24.9 0
1 42.9 42.2 1 44.0 Stubborn and
2 21.7 2.6
1 44.6 21.8 1 40.7
2 25.5 4.1
1 31.0 9.8 1 28.8
Sulks a lot
2 7.6 1.6
1 21.9 4.4 1 23.7
2 10.4 0.6
1 63.2 1.9 1 19.9
Talks of suicide
2 32.4 0.3
Has rages 1 28.8 19.7 70.1 1 34.5 4.2
2 25.0 3.2 *** 2
1 18.8 6.9 1 8.5 Too cleanly &
2 22.5 3.5
1 20.3 4.8 1 10.7
2 20.3 0.6
1 23.8 3.5 1 13.1
Passive, no energy
2 6.6 0.3
1 46.1 6.6 1 44.3
2 21.7 0.9
1 22.7 7.9 1 21.7
2 8.6 0.3
1 0.6 3.2 1 11.9
2 4.4 20.8
1 39.7 14.1 1 41.1
2 48.4 1.3
* p< .05, ** p< .01, *** p< .001,
Note. The OCS Nelson items are marked with a N.
Some CBCL-items of particular interest are marked in italics.
OCD: Obsessive-Compulsive Disorder (OCD) group.
CPO: Child Psychiatric Outpatient group.
SS: School Sample.
A CBCL score of 1: “Somewhat or sometimes true”; 2: “Very often or often true”
Results of logistic regression with backward elimination using clinical status (OCD versus
clinical CPO) as dependent variable and the 10 CBCL items most strongly associated with
OCD rather than with clinical CPO status.
OR (CI 95%)
Compulsions 2.2 .32 49.0 .001 9.2 (5.0-17.2)
Worries .6 .34 3.4 .065 1.9 (1.0-3.6)
Constant -3.3 .42 62.8 .001 .04
Area under the curve (AUC) in ROC analysis for the three study versions of the OCS-
95% Confidence Interval
Nelson OCS .91 .02 .001 .87 .94
LogReg OCS .96 .01 .001 .94 .98
Geller OCS .95 .01 .001 .93 .98
Figure 1 ROC-curves for the three OCS-scales
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