The Child Behaviour Checklist (CBCL) is a widely used questionnaire in research on developmental psychopathology (Achenbach & Rescorla, Reference Achenbach and Rescorla2001). It is composed of 118 questions filled by the parents and provides T scores for three general domains (Total, Internalizing and Externalizing problems), eight Empirically Based Syndromes Scales (Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems, Attention Problems, Rule-Breaking Behaviour and Aggressive Behaviour) and six Diagnostic and Statistical Manual of Mental Disorders (DSM)-oriented scales (Affective Problems, Anxiety Problems, Somatic Problems, Attention Deficit/Hyperactivity Problems, Oppositional Defiant Problems and Conduct Problems). In the past few years, it has been proposed that the sum of T scores in three Syndromes scales (i.e. Aggressive Behaviour, Anxious/Depressed and Attention Problems) could be used to identify CBCL-Juvenile Bipolar Disorder index (CBCL-JBD index; Biederman et al. Reference Biederman, Petty, Monuteaux, Evans, Parcell, Faraone and Wozniak2009). However, the diagnostic value of this index in detecting JBD has been disconfirmed afterwards because of its low sensitivity and specificity (Volk & Todd, Reference Volk and Todd2007). Recently, the CBCL-JBD index has been renamed as ‘CBCL-Dysregulation Profile’ (CBCL-DP) index, as it better detects children with ‘a persisting deficit of self-regulation of affect and behaviour’ (Holtmann et al. Reference Holtmann, Buchmann, Esser, Schmidt, Banaschewski and Laucht2011). Several studies confirmed that CBCL-DP does not represent an early manifestation of JBD and it is not linked to a specific psychiatric diagnosis (Ayer et al. Reference Ayer, Althoff, Ivanova, Rettew, Waxler, Sulman and Hudziak2009), rather it is a developmental risk marker of poor overall functioning in adult life (Holtmann et al. Reference Holtmann, Buchmann, Esser, Schmidt, Banaschewski and Laucht2011, Table 1). In large population-based samples (Ayer et al. Reference Ayer, Althoff, Ivanova, Rettew, Waxler, Sulman and Hudziak2009; Althoff et al. Reference Althoff, Verhulst, Rettew, Hudziak and van der Ende2010, Table 1), this index usually indicates a more severe psychopathology, and studies on clinical populations also confirmed these results. Most of the studies on clinical subjects involved Attention Deficit Hyperactivity Disorder (ADHD). Spencer et al. (Reference Spencer, Faraone, Surman, Petty, Clarke, Batchelder, Wozniak and Biederman2011, Table 1) found that children with ADHD and CBCL-DP were more socially impaired and they had increased probability of comorbid disorders (such as anxiety and disruptive behaviour disorders) compared to non-CBCL-DP ADHD. Consistent findings were reported by follow-up studies on ADHD children (Biederman et al. Reference Biederman, Petty, Monuteaux, Evans, Parcell, Faraone and Wozniak2009; Halperin et al. Reference Halperin, Rucklidge, Powers, Miller and Newcorn2011, Table 1).
Summary of the studies described in this review
ACC, anterior cingulate cortex; BDI, Beck Depression Inventory; CAS, Child Assessment Schedule; CDRS, Children's Depression Rating Scale; CGAS, Children's Global Assessment Scale; CIDI, Composite International Diagnostic Interview; DICA, Diagnostic Interview for Children and Adolescents; DISC, Diagnostic Interview Schedule for Children; FTND, Fagerström Test for Nicotine Dependence; GAF, Global Assessment of Functioning; GAPD, Global Assessment of Psychosocial Disability; IPDE, International Personality Disorder Examination; KSADS-E, Epidemiological version of Kiddie-Schedule for Affective Disorder and Schizophrenia for Children; MEG, Magneto-Encephalography; MEI, Mannheim Parent Interview; MEL, Munich Events List; SAICA, Social Adjustment Inventory for Children and Adolescents; SES, Socio-Economic Status; SCID, Structured Clinical Interview for DSM-IV; SMD, Severe Mood Dysregulation; SUQ, Substance Use Questionnaire; YMRS, Young Mania Rating Scale; YSR, Youth Self-Report.
Studies on heterogeneous clinical populations found results in the same direction. Meyer et al. (Reference Meyer, Carlson, Youngstrom, Ronsaville, Martinez, Gold, Hakak and Radke-Yarrow2008) analysing data from a 23 years longitudinal study on at-risk youth for psychiatric disorders (i.e. offspring of parents with mood disorders), found that CBCL-DP during childhood is associated with later anxiety disorders, ADHD, cluster-B personality disorders, bipolar disorder (BD), drug abuse and suicidal ideation (Table 1). Similar results were found on 9024 clinical subjects with non-specified psychiatric pathologies (Jucksch et al. Reference Jucksch, Salbach-Andrae, Lenz, Goth, Döpfner, Poustka, Freitag, Lehmkuhl, Lehmkuhl and Holtmann2011) and on 325 children that presented risk factors associated with obstetric complications and psychosocial status (Holtmann et al. Reference Holtmann, Buchmann, Esser, Schmidt, Banaschewski and Laucht2011, Table 1).
As to the neurobiological bases of this syndrome, so far few studies have investigated the biological and neural substrates of the CBCL-DP. It has been shown that this profile is highly inheritable (Doyle et al. Reference Doyle, Biederman, Ferreira, Wong, Smoller and Faraone2010) and that it is associated with genetic regions found in adult BD, schizophrenia, autism and ADHD, like 1p21 (Table 1).
In parallel studies, Rich et al. (Reference Rich, Carver, Holroyd, Rosen, Mendoza, Cornwell, Fox, Pine, Coppola and Leibenluft2011) using the magnetoencephalography (MEG) compared children with Severe Mood Dysregulation (SMD), characterized by abnormal mood, hyper-arousal and increased reactivity to negative emotional stimuli, being therefore very similar to the CBCL-DP (Leibenluft, Reference Leibenluft2011), to children with BD and controls during a Posner Affective Task. This task consists of a modified Posner Task, in which error feedbacks are modified to elicit frustration. The authors found that SMD youth showed greater arousal following negative feedback than both BD and controls, and they responded to negative feedback with significantly greater activation of the anterior cingulate cortex (ACC) and the medial frontal gyrus (MFG) than controls, while BD youth showed dysfunction in the superior frontal gyrus (SFG) and insula (Table 1). It seems therefore that specific cerebral substrates are involved in childhood SMD, thus supporting the hypothesis of a specific syndrome not related to JBD (Leibenluft, Reference Leibenluft2011).
In conclusion, there is evidence that the CBCL-DP represents a useful index for identifying children and adolescents at risk for psychiatric problems in early adulthood. Given the ease of administration of the CBCL and its widespread use, this could become a powerful and low-cost tool to detect children who need early intervention for the prevention of mental illnesses, reducing the subsequent cost of treatment for psychiatric disorders (Kessler et al. Reference Kessler, Aguilar-Gaxiola, Alonso, Chatterji, Lee, Ormel, Üstün and Wang2009). However, few studies have been carried out so far to explore the potential neurobiological bases of patients with CBCL-DP. More neuroimaging investigations, coupled with neuropsychology and genetics, are therefore expected to further delineate the neural underpinnings of CBCL-DP, which may ultimately help in planning specific strategies to prevent major psychopathology during development.
