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. Author manuscript; available in PMC: 2009 Feb 1.
Published in final edited form as: J Pediatr Nurs. 2008 Feb;23(1):20–27. doi: 10.1016/j.pedn.2007.07.005

Analysis of Two Measures of Child Behavior Problems by African-American, Latino, and Non-Hispanic Caucasian Parents of Young Children: A Focus Group Study

Abigail B Sivan 1, Alison Ridge 1, Deborah Gross 1, Reginald Richardson 1, Julia Cowell 1
PMCID: PMC2249759  NIHMSID: NIHMS40125  PMID: 18207044

Recent calls for early identification of mental health problems in preschoolers (U.S. Public Health Service, 2000) presume ready availability of both instruments and professionals trained to make these assessments. Pediatric nurses have responded to this call by incorporating mental health assessments in their daily practice. Programs such as KySS (Melnyk & Moldenhauer, in press) have been developed to help pediatric nurses broaden their scope of practices to include a greater focus on child mental health. Similarly, post-graduate training programs in mental health nursing (Perraud, Delaney, Carlson-Sabelli, Johnson, Shepherd & Paun, 2006) are redesigning their curricula to accommodate the mental health training demands of nurses who are expected to assess and treat mental health problems in their client populations.

Research shows that early identification and treatment of behavior problems is essential for preventing more serious and costly problems in later childhood (Keenan & Wakschlag, 2000). Without effective intervention, behavior problems in the first 5 years of life are likely to affect children’s academic and interpersonal success in later years. However, it is critically important that assessments are based on measures that are meaningful and valid for different racial/ethnic and income groups. Using measures that are not valid across different racial/ethnic and income groups can lead to erroneous conclusions about children’s mental health, inappropriate recommendations about which children need intervention, and alienation of parents who feel they and their children have been misjudged by health care providers.

Traditionally, questionnaires asking parents to report the presence and frequency of a range of potential behavior problems are used to screen for mental health problems in young children (Sattler, 2002). Two of the most widely used parent-report measures are the Child Behavior Checklist (CBCL) (Achenbach & Rescorla, 2000) and the Eyberg Child Behavior Inventory (ECBI) (Eyberg & Pincus, 1999).

Several studies have found systematic differences in CBCL and ECBI scores by race/ethnicity and family income, with low-income and ethnic minority children often receiving higher behavior problem scores than non-Latino White children from more economically advantaged homes (Keiley, Bates, Dodge & Pettit, 2000; Raadal, Milgrom, Cauce & Mancl, 1994; Sandberg, Mayer-Bahlburg & Yager, 1991). These findings suggest that further research is needed to determine whether differences are related to (1) the reliability and validity of these instruments in different racial/ethnic and income groups or (2) how parents from different backgrounds perceive these questionnaires. Differences in reliability and validity could lead to inaccurate assessments of behavior problems in children from different racial/ethnic and income groups. Parent perceptions of the CBCL and ECBI as culturally biased, irrelevant, and incomprehensible could affect how they answer items on these measures.

An evaluation of the reliability and validity of the CBCL and ECBI among African American, Latino, and non-Latino Caucasian preschool children was recently addressed. Specifically, Gross et al. (Gross, Fogg, Young, Ridge, Muennich Cowell, Richardson, & Sivan, 2006; Gross, Fogg, Young, Ridge, Cowell, Sivan, & Richardson, in press) completed a rigorous analysis of the psychometric properties of the CBCL and ECBI in a group of 682 parents of 2–4 year old children, stratified by parent race/ethnicity, family income, and language spoken (Spanish versus English). The findings of those studies supported the reliability and validity of the CBCL and ECBI across the different racial/ethnic, income, and language groups. Not addressed was how parents viewed these instruments and whether parents felt that the CBCL and ECBI would adequately identify their concerns related to child behavior problems.

The purpose of this study was to examine how African-American, Latino, and non-Latino Caucasian parents of 2–4 year old children from different economic backgrounds perceived the CBCL and ECBI. Using focus group methodology (Krueger and Casey, 2000), the authors evaluated (1) how well parents from different racial/ethnic and economic backgrounds thought the CBCL and the ECBI captured the kinds of behaviors they believe are problems in young children, (2) the extent to which items on these scales were perceived as culturally insensitive, upsetting, or useless, and (3) whether the items were easily understood and comprehensible to parents from different backgrounds.

Method

This study was part of a larger study evaluating the reliability and validity of the CBCL and ECBI among a racially/ethnically and economically diverse sample of parents of 2–4 year old children (Gross, et al., 2006; Gross, et al., in press). Most parents recruited to participate in the focus groups had been participants in this larger study. The instruments and methods used in the focus group study are described below.

Instruments

Two child behavior problem measures were the focus of this study: The Child Behavior Checklist (CBCL) and the Eyberg Child Behavior Inventory (ECBI). The CBCL includes 99 behavioral items asking parents to rate each on the extent to which they believe the child exhibits that behavior on a scale of 0 (“not true” about my child) to 2 (“very true or often true” about my child) over the past two months. The items are clustered into one of two subscales. The “externalizing” subscale assesses child problems related to aggression and inattention. The “internalizing” subscale assesses child behaviors associated with anxiety and depression. Scoring the CBCL yields standardized T-scores for each subscale and for the total CBCL scale. These T-scores are used to estimate a child’s level of impairment against a standardized cutpoint indicative of clinically significant behavior problems. According to the scale authors, the CBCL is written at a 5th grade reading level. Numerous studies have supported the reliability and validity of the CBCL (Breitenstein, Hill, & Gross, 2007; Calkins & Dedmon, 2000; Heller, Baker, Henker, & Hinshaw, 1996; Koot, Van den Oord, Verhulst, & Boomsma, 1997). Currently, two versions of the CBCL are used with children, one for toddlers and preschoolers (CBCL/1½-5) and one for school-aged and adolescent children (CBCL/6 -18). This study focused on the CBCL/1½-5.

The ECBI assesses behavior problems in children ages 2 through 16 years (Eyberg & Pincus, 1999; Eyberg & Robinson, 1983). There are two ECBI subscales, each consisting of 36 items. The “intensity” subscale measures the frequency with which the child exhibits each of the 36 behavior problems on a scale of 1 (“never” occurs) to 7 (“always” occurs). The “problem” subscale instructs parents to indicate whether each of the 36 behaviors is considered to be a problem for the parent by circling “yes” (the behavior is a problem) or “no” (the behavior is not a problem). Like the CBCL, ECBI scores above a standardized cutpoint on the intensity or the problem subscales are indicative of clinically significant behavior problems. Unlike the CBCL, the ECBI items focus exclusively on externalizing problems (i.e., aggression and inattention); it does not include internalizing behavior problems (i.e., those related to depression and anxiety). The reliability and validity of the ECBI has been supported in prior research (Burns & Patterson, 2001; Eyberg & Ross, 1978; Funderburk, Eyberg, Rich & Behar, 2003; Robinson, Eyberg & Ross, 1980).

Sample

All parents who had participated in the larger study were sent a letter asking if they would be interested in participating in a small group discussion with parents similar to themselves. Further, they were told that these focus group discussions would examine, in more detail, one of the behavior questionnaires they completed as part of the larger study. One-hundred thirty five parents responded to this letter indicating their interest in participating in the focus group study and 52% of those parents (n = 70) attended one focus group session. Among those who participated in the focus groups, mean parent age was 31 years (SD = 6.84).

Children of focus group parents included 26 (37%) 2-year olds, 21 (30%) 3-year olds, and 23 (33%) 4-year olds. Thirty-two children (46%) were boys and 38 (54%) were girls. There were no differences in parent age, child age, child gender, mean CBCL score, or mean ECBI score between those who participated in the focus group study and those in the larger study sample.

To understand how parents from different racial/ethnic, income, and language groups perceived the CBCL and ECBI, parents were grouped based on their self-identified race/ethnicity, income, and language-preference. It was assumed that greater group homogeneity would promote comfort among participants and greater willingness to share honest opinions (Krueger & Casey, 2000). Therefore, 15 focus groups were scheduled, stratified by race/ethnicity (African American, Latino, non-Latino White), reported income level (low versus middle/upper income), and preferred language (Spanish or English). Income level was defined as low income if reported household income was 50% below the state median income ($19,000) or greater than or equal to the state median income ($38,000). Focus group sizes ranged from 2 parents (n = 3 groups) to 7 parents (n = 4 groups). Composition of the 15 focus groups is presented in Table 1.

TABLE 1.

Composition of the 15 Focus Groups

Race/Ethnicity (Language Version) Income Level Instrument Size and Composition
Latino (Spanish) Low CBCL 6 moms
Latino (Spanish) Low ECBI 2 moms
Latino (English) Low CBCL 7 moms
Latino (English) Low ECBI 3 moms
Latino (English) Middle/Upper CBCL 6 moms 1 dad
Latino (English) Middle/Upper ECBI 7 moms
African American (English) Low CBCL 4 moms 1 grandmother
African American (English) Low ECBI 3 moms 1 dad
African American (English) Middle/Upper CBCL 2 moms
African American (English) Middle/Upper CBCL 5 moms
African American (English) Middle/Upper ECBI 6 moms
Non-Latino Caucasian (English) Low CBCL 1 mom 1 dad
Non-Latino Caucasian (English) Low ECBI 4 moms
Non-Latino Caucasian (English) Middle/Upper CBCL 5 moms
Non-Latino Caucasian (English) Middle/Upper ECBI 4 moms
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Conduct of the Focus Groups

All focus groups were held in classrooms at an urban medical center. Upon arrival, each participant signed a consent form and was given a name tag and copy of the questionnaire that would be discussed at that session (CBCL or ECBI). Parents were also given a pen and highlighter. All but one group were led by a mental health professional whose ethnicity matched those of the participants. The two Spanish-language focus groups were led by a bilingual Latina. Two additional team members served in the role of facilitator attending to logistics and another took field notes of the group discussion. Chairs were arranged in a circle; two tape recorders and microphones were centrally located to record the discussion.

As the session began, participants were asked to turn off cell phones. After the research team members and participants introduced themselves, the group leader reviewed the schedule and then read the questionnaire aloud so participants who could not read or not read quickly could still follow the discussion.

As the group leader read each item, participants were asked to do the following: 1) use the pen to circle any words or phrases that they did not understand, 2) circle any words of phrases people they knew might not understand, and 3) using the highlighter, highlight any words or phrases in the questionnaire that they found upsetting, offensive, or insensitive to their feelings or culture.

After this was completed, the tape recorders were turned on. Group members were asked, “If you saw a child aged 2 to 4 years old in your neighborhood and you said to yourself, ‘Wow, that kid’s got problems! What behaviors would you be seeing?”

The responses to this question were listed on a blackboard so that all participants could refer to them during the discussion that ensued. After the list was compiled, the parents were asked to review the list and consider whether each of the behaviors differed based on the child’s gender (more problematic for either boys or girls) or age (more problematic for a two year old than a four year old). Parents’ comments about age and gender were also noted on the blackboard and in the field notes.

Parents were then asked how well the questionnaire items read aloud earlier described those behaviors they had just identified as being ones they would expect to see in a child having problems. Specific examples were elicited from parents in the discussion.

Group leaders also asked participants to identify questionnaire items they thought were “not good”. These might include items that were “unclear”, “upsetting”, “culturally insensitive,” or “useless or a waste of time to ask”. Parents were then asked to talk about other or additional behavioral items that should have been included on the questionnaire but were not, i.e., behavior problems missing from the questionnaire. This discussion also generated a list of missing items and these too were noted on the blackboard and in the field notes.

Parents who participated in the ECBI focus groups were also asked to comment on the usefulness of having both intensity and problem subscale items to answer. Because each group discussed only one instrument, no group was asked to contrast the CBCL and ECBI. At the conclusion of each focus group, the leader summarized the group discussion and asked if there were other things the participants wanted to add. The focus groups lasted between 60 and 90 minutes and parents were paid $40 for their participation.

Analysis and Results

Data Analysis

Field notes were confirmed for accuracy by listening to the audiotapes. Written transcripts were generated for analysis. Focus group data were organized in a variety of ways that made for easy comparison of the similarities and differences among the groups. Behavior problem lists were examined by instrument across all groups and then compared across instruments. Similarly, items participants believed functioned differently by child age and gender were organized and compared by instrument, racial/ethnic group, and income group. The items from each instrument labeled: “good” and “not good” (unclear, offensive, upsetting, culturally insensitive, a waste of time) were organized into two spreadsheets for more efficient comparisons.

Those items that participants thought were missing from the CBCL or ECBI were also collated into four general categories: parent behavior, child behavior control, child affective state, and unclear but of concern. For each instrument, team members independently assigned each “missing item” to one of the four categories. To assess consistency of the ratings, a week later, these same team members collectively repeated this process and compared the assignments to those obtained earlier.

Findings

Across all 15 groups, irrespective of the group composition, parents most often identified externalizing behaviors (aggression, inattention, “acting out” or lacking control) as markers of problems for a child age 2 to 4 years. Items from the CBCL that were viewed as good identifiers of behavior problems were that child “destroys his/her own things,” “destroys things belonging to his/her family or other children,” “disobedient,” “gets in many fights,” “has temper tantrums or hot temper.” Examples of good identifiers from the ECBI were the child “yells or screams,” “destroying toys or other objects,” “teases or provokes other children,” “verbally fights with friends or siblings,” and “physically fights with friends or siblings.”

When participants were asked to identify what behaviors were “missing” from these instruments, parents from 12 of the 15 focus groups identified “swearing” as a problem that should be included. A number of other items were identified by at least one participant but in fewer than half of the focus groups. For the CBCL, the missing items included “bullying,” “hits self,” “steals,” “talks to self,” “lies,” “wets self,” “hits parents,” “yells at parents,” “bites,” “poor manners,” “doesn’t want to go to school,” “puts self down,” “ lacks respect for adults,” “bites nails,” “cannot identify self,” “too dependent,” “sibling rivalry,” “doesn’t cry when hurt,” “fussy/hard to please,” “obese,” “only interested in TV,” “constantly hungry,” and “lacks social skills.” Middle/upper income parents identified over twice as many missing items from the CBCL (M = 10.7) than did low-income parents (M = 5). However, this difference was largely due to the high number of missing items identified in one focus group comprised of African American parents with middle/upper incomes, in which 20 relevant behavioral indicators were viewed as missing from the CBCL.

The indicators of child behavior problems that participants felt were missing from the ECBI included “out of control behavior,” “won’t interact or play with other kids,” “cruel or abusive to animals,” “selfish,” “aggressive,” “threatening other children,” “ passive or withdrawn,” “spits,” “hits self,” “talks constantly,” “bites,” “disrespectful to adults,” “inappropriate sexual touching,” “runs away,” “fussy,” “extreme anger,” “looks unhappy/won’t smile,” “too friendly,” “prefers snacks to real food,” “too dependent,” and “fixates on things.” There were no differences in the number of ECBI items seen as missing by income level. However, African American parents identified the fewest items missing from the ECBI (M = 6.5) (M items missing were 11 for Latino focus groups and 12 for non-Latino Caucasian focus groups).

Across both instruments, there were no patterns in the types of behaviors seen as missing as it related to parent race/ethnicity or income group. Similarly, none of the groups consistently associated child problems with a particular gender or age. However, participants often discussed, in a stereotypic manner, that some behaviors were more prevalent, although not more problematic, in boys.

Parents did identify some items as “not good” because they were either “unclear” or “useless”. These items were viewed as either too vague or as something that could be viewed as normal behavior in young children. CBCL items that fit this category included the following: has “aches or pains without medical cause”; “can’t stand having things out of place”; “clings to adults or too dependent”; “diarrhea or loose bowels”; “doesn’t know how to have fun, acts like a little adult”; “gets into everything”; “picks nose, skin or other parts of body”; “problems with eyes without medical cause”; and “sulks a lot”. The items identified as “not good” on the ECBI were “dawdles in getting dressed”; “dawdles or lingers at mealtime”; “refuses to do chores when asked”; and “interrupts”.

A few items were found to be “offensive” or “upsetting.” The three items identified, all from the CBCL, were child “plays with sex parts too much”; “has diarrhea or loose bowels when not sick”; and “smears or plays with bowel movements”. During the discussion, it became clear that what the parents found upsetting about these items was that they themselves would be upset if their child exhibited this behavior. This was a different issue that than whether the items should have been included on the CBCL. One item was identified as offensive by Latino parents evaluating the Spanish version of the CBCL. The item asks parents to rate how often the child “vaga sin direccion,” intended to ask whether the child “wanders away.” However, some Spanish-speaking parents interpreted this item to mean “roam the streets [like a street walker]”, a translation they found upsetting and offensive.

During one of the ECBI groups, one parent questioned the wording of the instructions for the problem subscale. The instructions ask parents to indicate whether each of the 36 behaviors listed on the ECBI is a problem for the parent. One focus group parent interpreted this question as asking whether she had this problem rather than whether her child’s behavior was problematic for her. This misinterpretation was unexpected and raised the question of how many other parents interpreted the ECBI instructions in a similar manner. Since this feedback was received after more than half of the focus groups had been conducted, determining other participants’ interpretations of these instructions could not be obtained across all groups. However, questions about the ECBI directions were directly asked in three subsequent groups and no parent reported having the same misunderstanding.

Discussion

This study examined how African-American, Latino, and non-Latino Caucasian parents from different economic backgrounds perceived two of the most widely used questionnaires for screening behavior problems in young children. Fifteen focus groups of 70 parents stratified by race/ethnicity, income level, and language preference were convened to discuss either the Eyberg Child Behavior Inventory (ECBI) or the toddler/preschool version of the Child Behavior Checklist (CBCL). Parents were asked (1) how well they believed these rating scales captured relevant indicators of child behavior problems, (2) about the cultural sensitivity and acceptability of the scales, and (3) whether items on these scales were understandable.

Overall, the findings suggest that the ECBI and the CBCL are perceived by parents as useful, comprehensible, and acceptable. Moreover, the kinds of behaviors parents believed were relevant indicators of child behavior problems, namely those associated with aggression, inattention, and poor behavioral control, are consistent with the items included on the CBCL and ECBI.

Although parents identified a number of relevant behaviors they thought should have been included on the CBCL or ECBI but were not, only “swearing” was identified across the majority of focus groups. Thirteen of 15 focus groups listed “swearing” as an important indicator of child behavior problems that was missing from both scales. Numerous other items were offered by parents as relevant indicators that should be on a measure of child behavior problems. However, many of the behaviors were similar to items already found on these scales. For example, parents identified “not wanting to go to school” and “too dependent” as missing behavior problems on the CBCL. However, the CBCL does include an item on whether the child “doesn’t want to go out of the home” and another on whether the child “clings to adults or too dependent.” Other items identified as missing on the CBCL may not be developmentally appropriate for toddlers and their inclusion on this scale may not be theoretically sound. Examples of the behaviors identified included: “steals,” “talks to self,” “fussy/hard to please,” and “lacks social skills.”

Some of the items identified by parents as missing on the ECBI were those indicative of internalizing problems (e.g., “won’t interact of play with other kids,” “passive or withdrawn,” and “looks unhappy/won’t smile”). These omissions from the ECBI are consistent with this scale’s focus on externalizing behaviors. However, several externalizing behaviors were also identified as missing from the ECBI (e.g., “cruel or abusive to animals,” “bites,” and “disrespectful to adults”). Parents identified more “unique” missing items from the ECBI than the CBCL. However, this difference makes sense in light of the fact that the ECBI has many fewer items (36 items) than the CBCL (99 items). Indeed, one of the advantages of the ECBI over the CBCL in practice settings is its brevity. However, a possible disadvantage of this brevity is that important indicators of child behavior problems are not represented on the scale.

It is important to note that aside from “swearing”, none of the missing indicators of child behavior problems were identified in more than 3 of the 15 focus groups. In addition, there was no discernable pattern in the type of behavior parents thought missing from the behavior problem scale and the participants’ racial/ethnic or income background. These results suggest that although the ECBI and CBCL may not be inclusive of all problematic behaviors parents believe to be relevant, the items that are included are considered representative across racial/ethnic and income groups.

With the exception of one CBCL item in which the Spanish translation was questioned by Latino parents, neither instrument was perceived to be biased or culturally insensitive. Three CBCL items related to sexual behavior and feces were viewed as upsetting to parents, mainly because parents did not want to think about those kinds of problems. The parents did report, however, that these items were behaviors to be concerned about in children. The ECBI does not include questions about sexual behavior or playing with feces and none of the ECBI items were identified as being culturally biased, insensitive, or upsetting.

In one of the focus groups, one parent misunderstood key instructions on how to complete the problem subscale of the ECBI. Although this did not appear to be a pervasive problem among participants, it warrants our attention. Practitioners using the ECBI may want to clarify the instructions for completing this measure by pointing out that parents should report only on their child’s behavior, rather than their own behavior.

Another issue is translating psychological concepts from English and Spanish; translation is a process that is often fraught with problems. When using the Spanish version of the CBCL, it may be useful to talk about the intent behind item #95 that asks about the child’s propensity to wander so that a parent does not become offended.

The findings are consistent with those reported by Oesterheld and Haber (1997). Their study also used a focus group format to examine the perceived acceptability of the CBCL and the Conner’s Parent Rating Scale (CPRS) with Dakotan/Lakotan parents. Thirty-three parents from 4 reservations were enrolled into 4 focus groups; each group discussed both child behavior instruments. Similar to the results obtained in this study, the Native American parents found the CBCL and CPRS useful and not insensitive to their culture. However, these parents expressed concern that some words or idioms were difficult to translate and could lead to misunderstandings between Native American parents and health care providers.

The results also point to the need for additional research. As newer scales such as the Behavior Assessment System for Children (Reynolds & Kamphaus, 2004) increasingly enter into clinical practice, they too should be examined for acceptability by parents from varying backgrounds. Also worthy of further exploration is why parents in these focus groups identified “externalizing” behaviors as more problematic than “internalizing” behaviors. It is possible that parents identify behaviors as being problematic if they negatively affect the larger community rather than only the individual. Despite this, depression is one of the most prevalent and costly problems affecting children and adults (U.S. Public Health Service, 2000; National Institute of Mental Health, 2001; McNaughton, D.B., Cowell, J.M., Gross, D., Fogg, L. & Ailey, S.H., 2004). As such, internalizing behavior problems are also important to screen in early childhood.

Although these findings cannot be generalized beyond the 70 parents who participated in these focus groups, they do point to several potential implications for practice. First, the data suggest that parents may prefer the ECBI over the CBCL because it does not contain items that ask about children’s sexual behavior and playing with feces. However, the data also suggest that compared to the CBCL, the ECBI does not include as many relevant indicators of child behavior problems.

In practice, nurses need to weigh the benefits of using a measure that parents may find less onerous to complete against one that may provide a less comprehensive assessment of child behavior problems. If practitioners choose the ECBI as the preferred screening instrument, they may want to ask parents about additional externalizing and internalizing behaviors not found on the ECBI to gain a fuller understanding of the child’s mental health. If instead, practitioners select the CBCL, they may want to warn parents there may be items they find upsetting to think about and that if those are concerns they have about their children, to feel free to talk about them.

These limitations and considerations, notwithstanding, the findings make it clear that parents from diverse ethnic backgrounds and income levels found these measures as useful, comprehensible, and acceptable as do the practitioners for whom they were originally developed.

Acknowledgments

This study was supported by a grant from the National Institute of Nursing Research, R01 NR07750. The authors thank Rocio Munoz-Dunbar, PhD and Claudia Murphy for their skilled and diligent handling of the Latino focus groups.

Footnotes

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