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. Author manuscript; available in PMC: 2023 Feb 14.
Published in final edited form as: J Autism Dev Disord. 2021 May 30;52(5):2061–2074. doi: 10.1007/s10803-021-05103-8

Utilizing the Child Behavior Checklist (CBCL) as an Autism Spectrum Disorder screener and outcome measure for a social skills intervention for Autistic Adolescents

Alexis A Arias 1,*, Madison M Rea 2,*, Elyse J Adler 2, Angela D Haendel 3, Amy Vaughan Van Hecke 2
PMCID: PMC9926906  NIHMSID: NIHMS1867923  PMID: 34052960

Abstract

Exploration of potential preliminary screeners, and examination of social intervention outcomes for effects on comorbid symptoms is imperative. The Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) provides a potential ASD screener and intervention outcome evaluation. This study had two aims: 1) to examine CBCL scales scores as a potential ASD screener; 2) to investigate PEERS® outcomes via the CBCL for Autistic adolescents. Results indicated elevated scores on four CBCL scales in the ASD groups, contrasted to a typically-developing group. Furthermore, decreases in the two CBCL scales for adolescents that received the intervention were found. Findings support prior research indicating a unique CBCL elevation pattern as a potential screener for ASD, and provide additional support for the efficaciousness of PEERS®.

Keywords: Autism, Adolescents, Screener, Child Behavior Checklist

Social challenges in Autism Spectrum Disorder (ASD) have prompted increasing research on the consequences of Autistic individuals receiving interventions (Gates et al., 2017), particularly in light of the direct negative outcomes of inherent social challenges (e.g., lower quality and quantity of friendships), and collateral negative outcomes (e.g., loneliness, depression, and victimization; Adams et al., 2016; Kasari et al., 2011; Mazurek & Kanne, 2010)). These social difficulties have been posited to be derived from limited positive reinforcement from social interactions, rather than a lack of social interest (Bauminger, 2002; White et al., 2007). As inclusive education of Autistic children without a cognitive disability (CD) becomes more common (Macdonald et al., 2018), it is likely they may be at higher risk for encountering punishing consequences (e.g., peer victimization) following poor social interactions, if social challenges are not addressed. These consequences can lead to feelings of isolation and increase their risk of depression (Baker & Bugay, 2011). As such, many early interventions have focused on skills that develop social communication and motivation (Fuller & Kaiser, 2020; Vernon et al., 2019), and to deter the derailment of later social skills due to low social motivation and difficulties in communication (Chevallier et al., 2012; Jones & Klin, 2009).

However, inherent social difficulties in ASD are not the only contributing factors to building friendships, as a variety of common comorbidities in ASD have been linked to friendship quantity and quality, such as number of friends, and reciprocal trust and companionship, respectively (Bagwell et al., 2001; Mazurek & Kanne, 2010; Oppenheimer & Hankin, 2011; Rodebaugh et al., 2014).

Comorbidities

Previous studies have found that the majority of Autistic children and adolescents have at least one comorbid mental health disorder with estimates ranging from 38.1% - 95% (Joshi et al., 2010; Lecavalier et al., 2019; Tsai, 2014). Additionally, not all who have a comorbid symptoms have a formal medical diagnosis for the comorbidity (Casanova et al., 2020; Guerrera et al., 2019). Attention deficit/hyperactivity disorder (ADHD), anxiety, and depression are amongst the most common ASD comorbidities (Gnanavel et al., 2019; Kim et al., 2000; Mayes et al., 2011; Sikora et al., 2012; Simonoff et al., 2008; van Steensel et al., 2011, 2013), and show a higher prevalence rate in Autistic individuals than in the general population (Faraone et al., 2003; Kirsch et al., 2020).

In terms of comorbid ADHD, this comorbidity contributes to greater challenges in communication, socialization, and psychosocial functioning for adolescents with ASD beyond those found in ASD alone (Holtmann et al., 2007; Sikora et al., 2012). Meanwhile, anxiety and depression have been found to be associated with greater social challenges, such as quality and quantity of friendships, lower self-esteem, and heightened feeling of loneliness (Bellini, 2004; Chang et al., 2012; Locke et al., 2010; Mazurek & Kanne, 2010; White & Roberson-Nay, 2009). Furthermore, these symptoms have been posited to be linked to social challenges by contributing to further social withdrawal, either as a result of underlying anxiety and depression (Mazurek & Kanne, 2010; Whitehouse et al., 2009), or anxiety and depression resultant from preexisting negative experiences with peers (e.g., victimization and rejection; Chang et al., 2012). Whether it is the former or latter driving increased social withdrawal, avoidance of these social experiences may limit interactions with peers for Autistic individuals; therefore limiting opportunities to improve social skills and creating a detrimental cycle (Chang et al., 2012). Although there are a number of efficacious social skills intervention for increasing social skills in autistic youth (Gates et al., 2017), it is imperative to evaluate not only direct outcomes (e.g., social skills and friendships), but also comorbid symptoms outcomes; particularly given that social skill deficits are not the only barriers to friendships (e.g., Chang et al., 2012; Locke et al., 2010).

The PEERS® Intervention

The Program for Education and Enrichment of Relational Skills (PEERS®) is one efficacious, parent-mediated, social skills intervention that has been shown to increase social skills knowledge and social ability (Laugeson et al., 2009, 2012; Authors, 2016b; Authors, 2014). It has also been shown to ameliorate symptoms of depression and anxiety in adolescents (Authors, 2017; Authors, 2014). PEERS® for adolescents is a manual-based intervention designed for Autistic individuals with a verbal IQ ≥ 70 and between the ages of 12-18 years (Laugeson et al., 2009). PEERS® is conducted via once weekly meeting for 14 weeks in which simultaneous parallel parent and adolescent groups receive didactic lessons on social skills such as trading information, entering a conversation, and appropriate use of humor (refer to Supplementary Table 1 for a list of all session topics). Lessons for the adolescents consist of a homework review, didactic, role-play, and behavioral rehearsal for the adolescent group. Parents group sessions consist of homework reviews, didactic, and troubleshooting parent concerns regarding their child’s homework completion and skill acquisition, such as challenges in applying didactic material (e.g., not being an interviewer during two-way conversations) outside of PEERS®. PEERS® has been replicated within the United States, outside the original site at University of California, Los Angeles (UCLA; Authors, 2016a; T. L. Hill et al., 2017; Authors, 2014), and also shown efficacy for making and keeping friends in different cultures and international sites (Jagersma et al., 2018; Rabin et al., 2018; Shum et al., 2019; Yoo et al., 2014). However, the outcomes of PEERS® have yet to be examined utilizing a broadband measure of behavioral and emotional symptoms that measures both social and comorbid symptoms common in ASD.

ASEBA Child Behavior Checklist

One broadband measure for assessing behavioral and emotional symptoms is the Achenbach System of Empirically Based Assessment (ASEBA; Achenbach & Rescorla, 2001) Child Behavior Checklist (CBCL; caregiver-report). The CBCL is composed of eight DSM-oriented scales, eight syndrome scales, two combined scale scores (Internalizing symptoms, Externalizing symptoms) and a total score. Prior research utilizing the syndrome scales have explored the validity of utilizing the CBCL as a screener for ASD (Bölte et al., 1999; Havdahl et al., 2016; Mazefsky et al., 2011; Noterdaeme et al., 1999). To be clear, in referencing a “screener” it is not suggested to act as an equivalent or substitution of a diagnostic evaluation (e.g., an ADOS), but rather functioning as an efficient method to screen for individuals at a high-risk for an ASD diagnosis; thus, suggesting a further evaluation for the diagnosis. Notably, the extant literature is limited and has yet to establish the validity of the utilization of the CBCL as an ASD screener; however, preliminary studies have shown agreement in showing elevated symptom reports in children with ASD on the following syndrome scales: Withdrawn/Depressed, Social Problems, Thought Problems, and Attention Problems (Bölte et al., 1999; Mazefsky et al., 2011; Noterdaeme et al., 1999).

As the prevalence of ASD diagnosis continues to increase (Chiarotti & Venerosi, 2020), and the known positive-effects of early identification and intervention (Council, 2001; Reichow & Wolery, 2009), it is important to explore the use of existing measures as a screener for individuals at high-risk for an ASD diagnosis to amplify access to evaluations and interventions. Having one broadband measure that can function both as a separate screening measures for each mental health concern, as well as a ASD screener, may allow for more accessible ASD screening at schools and general healthcare institutions that may have limited financial resources.

In addition to the possibility of being utilized as a screener, the CBCL syndrome scales may also function as an outcome measure of a social intervention known to moderate both core ASD symptoms, and comorbid symptoms; therefore, providing further insight into direct and collateral intervention effects.

Summary and Aims

The purpose of the current study was twofold. First, in light of prior discrepant research findings (Bölte et al., 1999; Mazefsky et al., 2011; Noterdaeme et al., 1999), namely in the pattern of scale score elevations, a replication of CBCL scale scores examination for differences between two adolescent ASD and age-controlled, IQ-matched TD samples was conducted. Notably, only Mazefsky et al. (2011) used the newest version of the CBCL (Achenbach & Rescorla, 2001) which decreases the age range from 4-18 years of age to 6-18 years, and included an IQ ≥ 70 as an inclusion criteria; therefore, lessening potential for confounds due to the child’s cognitive abilities. Therefore, as the most recent study to examine a CBCL scale elevation pattern as a screener for ASD and its use of the newest version of the CBCL, our study was crafted to most closely replicate on Mazefsky and colleagues (2011). Second, this study investigated the outcomes of PEERS® for adolescents via the CBCL scales to examine the use of a broadband measure of behavior to quantify outcomes of the PEERS® intervention.

Method

Participants

Two hundred and twenty-one participants (NASD=133; NTD=47) were recruited and enrolled in the current study. Participants were Autistic adolescents without intellectual disability (Verbal IQ ≥ 70), and typically-developing (TD) adolescents. All autistic participants were recruited from local agencies and community support groups for Autistic individuals, and an existing waiting list at an Autism Clinic at a private university. Advertisements posted at various locations on a University campus were used to recruit TD participants. Institutional Review Board (IRB) approval was obtained as part of a larger Randomized Controlled Trial (RCT), and informed consent and assent was obtained from all individual participants included in the study. A priori power analyses for the omnibus MANCOVA were conducted using G*Power 3.1.9.2 (Faul et al., 2009), with a moderate effect size ((f=.35; Selya et al., 2012)) was utilized. Results indicated that a total of 33 individuals would be needed to detect differences among groups at β = .80.

Procedure

Recruitment and Eligibility

Interested participants were screened via telephone by a research assistant to assess goodness of fit with the inclusion criteria. Autistic individuals and their participating family member, that met criteria were randomly assigned to the experimental (EXP) or waitlist (WL) group. Inclusion criteria for Autistic participants were: a) chronological age between 11 to 16 years of age; b) English fluency in the adolescent and their parent or family member willing to partake in the study; c) no history of adolescent major mental illness (e.g., bipolar disorder, schizophrenia, or psychosis); d) parental-reported social problems; e) no history of physical impairments, including hearing or visual difficulties, which would prevent the adolescent from participating in PEERS® activities; f) adolescent verbal IQ ≥ 70 as assessed via the Kaufman Brief Intelligence Test – 2nd Edition (KBIT-2; Kaufman & Kaufman, 2004); g) adolescent expressed interest in partaking in the group; h) a previous and current diagnosis of ASD, Asperger’s Syndrome, or Pervasive Developmental Disorder – NOS, with the current diagnosis (i.e., Autism Spectrum Disorder) confirmed via the Autism Diagnostic Observation Schedule – General (ADOS-G; Lord et al., 2001). The ADOS-G was utilized as the current study utilized a subsample of a larger RCT study with data collection beginning prior to the publication of the ADOS-2 (Lord et al., 2012). Therefore, for continuity with the original inclusion criteria, the ADOS-G was utilized.

Typically-developing participants were placed in the TD group. Inclusion criteria for TD adolescents were the aforementioned criteria a–f, and an absence of any developmental and mental health disorder. Age range was chosen to reflect previous PEERS® replications (Authors, 2014b; Authors, 2017; Authors, 2014). Refer to Authors (2014) for a complete list of inclusion criteria, participant recruitment methods, and compensation. Implementation details can be found in Supplement 2.

Data Collection

All groups (EXP, WL, and TD) attended a pre-intervention intake appointment for screening and completion of questionnaires. Upon completion of this intake, the EXP group proceeded to receive 14 weeks of PEERS® within two weeks of the appointment, whilst the WL and TD did not receive PEERS®. After PEERS® was completed, participants from all three groups returned for outtakes (no more than 16 weeks after intakes). Thereafter, the WL group received PEERS® during the following session block. Refer to Authors (2014) for a detailed account of treatment provision.

Attrition

Attrition was expected to approximate 20%, which is within the common range for randomized controlled trials (Hewitt et al., 2010). Participants who did not complete three PEERS® homework assignments, or missed three or more sessions of PEERS®, were dismissed from the intervention and were not included in analyses. The attrition from treatment rate in this study was 14.3%. A CONSORT diagram detailing participant recruitment, completion status, and data analysis status is found below.

Measures

A demographics form. and an adolescent health and medication history were completed at the intake appointments by all participants’ caregivers. Cognitive functioning was assessed for all adolescents utilizing the KBIT-2 to ascertain verbal IQ ≥ 70. The ADOS – G, which has served as the gold standard for assessment of ASD for almost twenty years, and shown high validity, inter-rater reliability, and inter-item correlation (Lord et al., 2001), was utilized to confirm ASD diagnosis in participants (the ADOS-2 was not yet available at inception of the study). The ADOS-G was administered and scored by examiners trained to a research-level reliability. Furthermore, Autistic adolescents were queried on their interest in partaking in a program teaching how to make and keep friends utilizing the Teen Mental Status Checklist (Laugeson & Frankel, 2010a).

The following experimental questionnaires were administered and completed by participants (i.e., adolescent and parent/caregiver) independently or read to the individual by a research assistant, when requested, at intake and outtake appointments. The Quality of Socialization Questionnaire – Parent Report (QSQ-P), Test of Adolescent Social Skill Knowledge (TASSK), and Social Responsiveness Scale 2 (SRS-2) were used to assess the efficacy of PEERS® in the current study, consistent with previous studies on PEERS® efficacy (e.g., Laugeson et al., 2012; Author et al., 2014). The CBCL was utilized to compare ASD versus TD group symptom endorsement on scales, and to examine intervention outcomes.

Experimental Questionnaires: Parent/Caregiver-Report.

Social Responsiveness Scale.

The SRS-2 (Bruni, 2014; Constantino & Gruber, 2005) was utilized to investigate difficulties in social communication. The SRS-2 is a well-validated 65-item measure, with five subscale scores (Social Awareness, Social Cognition, Social Communication, Social Motivation, and Autistic Mannerisms) and a Total Score, with higher scores indicating greater social communication challenges (Bruni, 2014). The Total Score was utilized for the purpose of this study. Internal consistency for the Total Score for this sample was good (α = .84).

Quality of Socialization Questionnaire.

The Quality of Socialization Questionnaire – Parent/Caregiver (QSQ-P; Laugeson et al., 2009) is composed of 12 items querying the frequency of adolescent get-togethers. Higher scores indicate a greater number of get-togethers the adolescent has attended, both hosted and invited-to, in the past month.

Child Behavior Checklist.

The ASEBA CBCL (Achenbach & Rescorla, 2001) is a broadband measure to assess clinically elevated internalizing and externalizing symptoms (Achenbach et al., 2002, 2003). Caregiver raters score symptoms of their adolescent on a Likert scale ranging from 0 (“Not True”) to 2 (“Very true”). Higher scores indicate greater symptom severity, with T-scores above 69 indicating clinically elevated symptoms (Achenbach & Rescorla, 2001). The CBCL syndrome scale scores have been found to have an internal consistency range of .67 to .83 and have been validated for the assessment of emotional problems in youth with ASD (Pandolfi et al., 2014). The internal consistency for these scales in this sample ranged from poor to excellent and were as follows: a) Anxious/Depressed Problems (α = .84); b) Withdrawn/Depressed (α = .78); c) Social Problems (α = .77); d) Somatic Complaints (α = .66); e) Thought Problems (α = .82), Attention Problems (α = .85), Rule Breaking (α = .65), and Aggression Problems (α = .89). All scales were retained, except Somatic Complaints and Rule-Breaking due to their poor reliability.

Experimental Questionnaires: Adolescent Self-Report

Test of Adolescent Social Skills Knowledge.

The TASSK (Laugeson & Frankel, 2010) is composed of 26 items designed to assess social skill knowledge targeted by the PEERS® intervention. Higher scores reflect greater knowledge of the social skills taught. Internal consistency (α = .53) was similar to the developer’s (α = .56; Laugeson et al., 2009). Alpha was deemed acceptable at this level by the developer as the questions cover several topics; thus, not expected to correlate closely with each other (Laugeson et al., 2009)

Data Analytic Plan

All statistical analyses were conducted using SPSS 26.0 (IBM SPSS Statistics for Mac, 2019). An alpha level of .05 was used for the significance criterion for hypothesis tests. One-way Analyses of Variance (ANOVAs), t-tests, and chi-square tests for independence were conducted to examine group differences on demographics variables. To confirm the treatment response to PEERS®, a chi-square of independence and an omnibus mixed-methods, repeated-measures MANOVA was conducted.

To examine the first aim, group differences (ASD EXP versus ASD WL versus TD) on endorsement of symptoms on CBCL Syndrome scales (the Anxious/ Depressed, Withdrawn/Depressed, Social Problems, Thought Problems, Attention Problems, and Aggressive Behavior scales), a Multivariate Analysis of Covariance (MANCOVA) was conducted. Post-hoc Least Significant Difference (LSD) pairwise tests were utilized to explore univariate scale differences between the three groups. Descriptive analysis was utilized to show the percentage of adolescents at or above the borderline clinical range (T-score ≥ 65) for each of the CBCL syndrome scales. It was hypothesized, as previously indicated (Bölte et al., 1999; Mazefsky et al., 2011; Noterdaeme et al., 1999), that scores on Anxious/Depressed Problems, Withdrawn/Depressed, Social Problems, Thoughts Problems, Attention Problems, but not Aggressive Behaviors would be elevated in the ASD samples compared to the TD sample. Aggressive Behaviors were not hypothesized to be significantly increased due to previous research showing that higher IQs in autistic children are associated with less physically aggressive behaviors (Farmer et al., 2015). Subsequently, logistic regression analyses were performed to look at the ability of CBCL scores to differentiate between the combined ASD groups and the TD group. This regression model was compared to the ability of the SRS-2 total score to differentiate between the two groups. Finally, to ascertain if the pattern of elevated scores was driven by comorbid diagnoses of ADHD (n=42), Depression (n=10), or Anxiety (n=15) in the ASD samples, a post-hoc analysis was conducted. The MANCOVA was re-run three times; excluding a different comorbid group each time.

To evaluate the second aim, change in CBCL Syndrome scale scores across the PEERS® intervention between groups, a Group (EXP versus WL) by Time (pre- versus post-intervention) mixed methods repeated-measures MANOVA was conducted on the aforementioned scales in Aim 1. Based on previous research on the effects of PEERS® on social ability, depressive symptoms, and anxiety symptoms (Authors, 2016a; Authors, 2017; Authors, 2014), it was hypothesized that the ASD group that completed PEERS® would show a significant decrease in the Anxious/Depressed, Withdrawn/Depressed, and Social Problems CBCL scales.

Results

Data Screening

Data were screened for normality, impossible values, and outliers. Univariate and multivariate tests for outliers showed no extreme outliers. Nineteen total values across five variables (.215% of total data) were found to be missing, one on the pre-test QSQ, seven on the post-test QSQ, six on parent race, three on family income, and two on child race. Missing demographic data were not replaced. Multiple imputation (five iterations) was utilized to replace missing items on outcome measures (Tabachnick & Fidell, 2013).

One-way analysis of Variance (ANOVA), t-tests, and chi-square tests for independence revealed no significant group differences on demographics variables of age, KBIT-2 Full Scale IQ, income, child race, parent race, child gender, or ADOS-G total scores. An ANOVA did reveal a significant difference between groups on the KBIT-2 Verbal IQ (p = .049). A Tuckey post-hoc test revealed that the TD group had a significantly higher Verbal IQ than the ASD WL group (p=.047). Therefore, Verbal IQ was controlled for in analyses that included the TD and WL group. Independent sample t-tests and chi-square of independence showed no significant differences between EXP and WL groups at pre-test on TASSK, SRS, or QSQ-P measures. See table 1 for means, standard deviations, F/t/χ tests, and p-values of demographics.

Table 1.

Participant Demographics

Group (n = 155)
Experimental
(n = 56)		 Waitlist
(n = 53)		 Control
(n = 46)		 F/t/χ p
M (SD) M (SD) M (SD)
Age (years) 13.32 (1.39) 13.42 (1.65) 13.30 (1.46) .081 .922
Gender (% male) 91.1 90.6 97.8 1.308 .520
Child Race (% Caucasian) 83.6 75 76.9 12.851 .117
Parent Race (% Caucasian) 86.4 84.3 76.9 9.315 .316
Income (%) 8.711 .367
 Under 25 K 5.6 13.5 0.0
 25-50 K 5.6 5.8 10.9
 50-75 K 18.5 17.3 21.7
 75-100 K 18.5 19.2 17.4
 Over 100 K 51.9 44.2 50
ADOS-G Total 11.48 (3.68) 12.38 (4.39) N/A −1.157 .250
KBIT-2 Verbal Subtest 102.27 (19.47) 100.32 (17.48) 108.37 (11.18) 3.069 .049
KBIT-2 Full Scale IQ 107.39 (18.38) 102.42 (17.14) 107.20 (13.60) 1.503 .226
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The following variables had different n-values: Experimental child race (n = 55), Experimental parent race (n = 52), Experimental income (n = 54), Waitlist child race (n = 52), Waitlist parent race (n = 51), Waitlist income (n = 52). KBIT-2 = Kaufman Brief Intelligence Test – Second Edition, ADOS-G = Autism Diagnostic Schedule – Generic.

Aim 1: CBCL Group Differences between Autistic individuals and TD individuals

A MANCOVA, controlling for Verbal IQ, indicated a significant omnibus main effect of group for the combined outcome variables (Wilks’ Lambda= .401, F(12, 292) = 14.071, p < .001). Follow-up univariate tests indicated significant differences in mean level symptom endorsements between groups in all syndrome scales. See Table 2 for means and standard deviations of CBCL scale scores. Least Significant Difference post-hoc analyses identified significant increased symptom endorsement in both ASD EXP and ASD WL contrasted with the TD Groups for the following CBCL scales: Anxious/Depressed, Withdrawn/Depressed, Social Problems, Thought Problems, Attention Problems and Aggressive Behaviors scales. No significant differences were found between the ASD EXP and ASD WL groups. Further examination of the elevated scores revealed that both ASD groups showed elevated mean scores above 2 SD from that of the TD group in the Anxious/Depressed, Withdrawn/Depressed, Thought Problems, and Social Problems. The two lattermost were elevated greater than 3 SD from that of the TD group.

Table 2.

Means, Standard Deviations, and Univariate F-tests for CBCL Pre-test scores

Experimental
(N= 56)		 Waitlist
(N=53)		 Typical Developing
(N=46)
Scales M (SD) M (SD) M (SD) F p *
Anxious/Depressed 7.68 (4.35) 7.85 (4.65) 2.02 (2.43) 33.328 < .001
Withdrawn/Depressed 5.95 (3.34) 6.26 (2.45) 1.13 (1.37) 46.230 < .001
Social Problems 7.45 (3.68) 7.43 (3.85) 1.17 (1.68) 58.886 < .001
Thought Problems 7.13 (3.68) 7.21 (4.81) 1.43 (1.88) 38.337 < .001
Attention Problems 9.89 (4.31) 10.81 (3.89) 2.80 (2.92) 64.456 < .001
Aggressive Behavior 7.91 (6.00) 8.91 (6.93) 3.09 (3.23) 14.403 < .001
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*

p-values remained significant after a LSD pairwise difference test.

Therefore, as mean symptom score endorsement was elevated in syndrome scales for both ASD groups (i.e., EXP and WL) versus the TD group, our hypothesis that all scales would be elevated in the ASD samples compared to the TD sample was supported.

Furthermore, descriptive analysis revealed that approximately 50% of participants in the ASD group (EXP + WL) reported symptoms at or above borderline clinical levels for Anxious/Depressed, Withdrawn/Depressed, Social Problems, Thought Problems, and Attention Problems scales. Thought problems showed the greatest disproportionality, indicating 70.6%, at elevated levels for the ASD group. The TD group mostly scored in the normative range with 8.7% being the highest percentage of TD adolescents reported at a borderline clinical level for any of the scales.

Logistic regression analysis using the CBCL scores from the elevated scales (Anxious/Depressed, Withdrawn/Depressed, Social Problems, Thought Problems, Attention Problems scales, Aggressive Behavior scales) was significant for the overall model (χ2 (6) = 142.632, p < .001). Table 4 shows the predicted versus observed diagnostic grouping based on this logistic regression. Correct identification occurred for 92.9% of the sample. Withdrawn/Depressed (t (1) = 6.869, p = .009), Social Problems (t (1) = 5.895, p = .015), Attention Problems (t (1) = 8.722, p = .003), and Aggressive Behavior (t (1) = 8.765, p = .003) were indicated to be a significant predictor of an Autism or Non-Autism (TD) Diagnosis.

Table 4.

Classification Table (Logistic Regression)

Pre-Intervention Autism Predicted
Control		 Percentage
Correct
Autism 105 4 96.3
Observed Control 7 39 84.8
Overall Percentage 92.9
Post-Intervention Autism Predicted
Control		 Percentage
Correct
Autism 46 10 82.1
Observed Control 7 39 84.8
Overall Percentage 83.3
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Post-Intervention utilized only the EXP group participants (nASD =56).

Logistic regressions using the SRS-2 total scores provided a comparable significant model (χ2 (1) = 30.706, p < .001) with correct identification of the overall sample at 92.3%. However, it showed greater sensitivity at the cost of specificity that was reflected by 100% correct Autism classification but only 73.9% correct identification of TD individuals. In contrast, the CBCL model correctly identified 96.3% of ASD individuals and 84.8% of TD individuals.

Post-Hoc Analysis.

To ascertain if the pattern of elevated scores was driven by comorbid diagnoses of ADHD, Depression, or Anxiety in the ASD samples, a post-hoc analysis was conducted. The MANOCOVAs revealed the elevation pattern remained significant during ADHD-exclusion (Wilks’ Lambda= .380, F(12, 208) = 10.789, p < .001), Depression-exclusion (Wilks’ Lambda=.393, F(12, 272) = 13.470, p < .001), and Anxiety-exclusion (Wilks’ Lambda= .397, F(12, 262) = 12.802, p < .001) analyses. There were no significant changes in the elevation pattern established by the primary analysis. Supplemental Table 2 provides F-values and p-values for the follow-up univariate tests.

PEERS® Efficacy

A chi-square test of independence revealed a significant difference between groups (EXP versus WL) on the number of get-togethers hosted and invited-to at post-test as measured by the QSQ-P (χ2= 3.957, p < .001, Cramer’s V = .639), contrasted with no significant difference between groups at pre-test. Specifically, the EXP group had a greater proportion of hosted and invited-to get-togethers at post-test than the WL group.

A mixed-methods repeated-measures MANOVA with the TASSK and SRS-2 as dependent variables revealed an omnibus time by group interaction (Wilks’ Lambda = .377, F(2,106) = 87.767, p < .001, partial η2= .623). Univariate tests showed a significant time by group interaction for both TASSK (F(1,107) = 163.590, p <.001, partial η2= .605) and SRS-2 (F(1,107) = 11.879, p = .001, partial η2= .100). Simple effect tests indicated that the EXP group showed a significant increase over time in social skill knowledge on the TASSK (F(1,107) = 384.941, p < .001, partial η2= .782), and a significant increase over time in social responsiveness on the SRS-2 mean total score (F(1,107) = 55.606, p < .001, partial η2= .342). Conversely, the WL group showed a significant difference over time in SRS-2 mean total score (F(1,107) = 5.983, p < .001, partial η2= .053), and no significant difference over time in the TASSK (F(1,107) = 2.885, p = .016, partial η2= .016). As expected, the PEERS intervention functioned as intended. See Table 5 for Means and Standard Deviations of Social measures.

Table 5.

Means and Standard Deviations for Social Challenges measures

Experimental Group (N=56) Waitlist-Control Group (N=53)
Variable Pre
M (SD)		 Post
M (SD)		 Pre
M (SD)		 Post
M (SD)
TASSK 12.46 (3.07) 21.45 (3.65) 12.94 (3.31) 13.53 (3.21)
SRS-2 106.95 (23.15) 86.02 (25.63) 104.04 (25.41) 97.00 (23.29)
QSQ- P (%)a
  0 48.2 61.5 7.8 60.8
  1 19.2 15.4 7.8 7.8
  2 10.7 5.8 13.7 7.8
  3 8.9 3.8 15.7 7.8
  4 3.6 9.6 17.6 3.9
  5 3.6 1.9 17.6 5.9
  6 - 8 3.6 1.9 13.7 2.0
  More than 8 1.8 0.0 5.9 3.9
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a

The following variables had a different n-value prior to imputation for analyses: EXP npost = 51,WL npre = 52, WL npost = 51. TASSK = Test of Adolescent Social Skill Knowledge, SRS-2 = Social Responsiveness Scale 2, QSQ-P = Quality of Socialization Questionnaire – Parent Report

Aim 2: PEERS® Treatment Outcomes on the CBCL

Our hypothesis was partially supported by a mixed-methods repeated-measures MANOVA indicating a significant omnibus time by group interaction (Wilk’s Lambda = .880, F(6,102) = 2.321, p =.038, Partial η2 = .120). Univariate tests showed a significant time by group interaction for the Withdrawn/Depressed (F(1,107) = 4.229, p = .042, Partial η2 = .038) and Social Problems (F(1,107) = 6.921, p = .010, Partial η2 = .061) scales. Simple effect tests indicated the EXP group showed a significant improvement in reported Withdrawn/Depressed (F(1,107) = 10.790, p = .001, Partial η2 = .092), and Social Problems (F(1,107) = 25.094, p < .001, Partial η2 = .190) symptoms. Conversely, the WL group showed no significant improvement in either Withdrawn/Depressed (F(1,107) = .107, p = .744, Partial η2 = .001) or Social Problems (F(1,107) = 1.447, p = .232, Partial η2 = .013) symptoms. Contrary to our hypothesis, univariate tests revealed no significant time by group interaction for the Anxious/Depressed scale (F(1,107) = 1.923, p = .168, Partial η2 = .018). See Table 6 for Means, Standard deviations and Univariate F-tests

Table 6.

Means, Standard Deviations, and Univariate Group by Time interaction

Experimental Group (N=56) Waitlist-Control Group (N=53)
Scales Pre
M (SD)		 Post
M (SD)		 Pre
M (SD)		 Post
M (SD)		 F p
Anxious/Depressed 7.68 (4.35) 6.57 (4.64) 7.85 (4.64) 7.64 (5.21) 1.719 .193
Withdrawn/Depressed 5.95 (3.34) 4.84 (3.34) 6.26 (3.45) 6.15 (3.73) 4.229 .042
Social 7.45 (3.68) 5.54 (3.56) 7.43 (3.85) 6.96 (4.19) 6.921 .010
Attention 9.89 (4.31) 8.77 (3.93) 10.81 (3.89) 9.66 (4.08) 0.002 .962
Thought 7.13 (3.68) 5.62 (3.48) 7.21 (4.81) 6.70 (4.39) 2.704 .103
Aggressive 7.91 (6.00) 6.75 (6.36)` 8.91 (6.93) 7.68 (6.66) 0.007 .931
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Logistic regression analysis using the CBCL scale scores from those identified as elevated in Aim 1, was conducted at post-intervention to examine if the scales still predicted ASD diagnosis for those that received the intervention (i.e., EXP group). Results showed that a significant overall model (χ2 (6) = 78.041, p < .001). However, correct identification of Autism decreased from 96.3% at pre-intervention to 82.1% at post-intervention (refer to Table 4). The Withdrawn/Depressed (t (1) = 6.542, p = .011), Attention Problems (t (1) = 6.129, p = .013), and Aggressive Behavior (t (1) = 6.081, p = .014) were indicated to remain significant predictor of an Autism or Non-Autism (TD) Diagnosis. Notably, Social Problems (t (1) = 1.915, p = .166) was no longer significant after the PEERS® intervention.

Discussion

The first aim of the current paper was replication of research examining the validity of utilizing the CBCL as an ASD screener in Autistic individuals with no intellectual disability on the CBCL. Results supported prior research findings; it reproduced the prior pattern reported in the literature (i.e., Bölte et al., 1999; Mazefsky et al., 2011; Noterdaeme et al., 1999) of several elevated scores across all CBCL syndrome-scales. Importantly, the Thought Problems Scale showed the highest proportion of elevated to borderline clinical level scores or above for the ASD group. This is in line with previous research indicating large proportions of Autistic children (i.e., two-thirds) falling in this range (Noterdaeme et al., 1999). Elevated Thought Problems scores have also previously been posited as the best ASD identifier, having shown nearly 100% accuracy, high sensitivity, and high specificity (83% and 71%; Duarte et al., 2003). It is likely that the high elevation in this scale is associated with restricted and repetitive behaviors found in ASD, as this scale contains items associated with DSM diagnostic criteria for repetitive and/or unusual behaviors. However, as Thought Problems have been shown to identify clinically significant psychosis (Salcedo et al., 2018), the elevation in Thought Problems may be most effective for screening for ASD when it is present in a pattern showing additional elevated scales, as previously suggested by two previous studies ((Bölte et al., 1999; Mazefsky et al., 2011) Another highly elevated scale was the Social Problems, whose items (e.g. doesn’t get along with peers, and teased by others) likely assesses social communication challenges inherent in ASD; as thus, it is highly elevated above normative levels.

In addition to the two abovementioned scales, the Anxious/Depressed, Withdrawn/Depressed, and Attention Problems scales were also elevated at a mean level. The percentage reported at, or above borderline clinical levels was also higher in ASD groups contrasted with the TD group. These elevations are likely independent of comorbid symptoms as our post-hoc analysis in Aim 1 showed that the elevation pattern remained unchanged when different ASD + X comorbidity were removed from the sample. These post-hoc analyses findings strengthen the plausibility that this elevation pattern is unique to Autistic individuals, and using the CBCL scales as a ASD screener should be further examined. Notably, one previous studies (i.e., Noterdaeme et al., 1999), did not show elevation of the anxious/depressed subscale. This may be linked to the current study’s sample being comprised of adolescents with no intellectual disability – a population which has been posited to experience greater anxiety (Lecavalier et al., 2017; Mayes et al., 2011; Mazurek & Kanne, 2010), whilst the previous study used a wider age range including 4 −18 year olds. These anxiety symptoms may not reach clinical levels for a formal diagnosis, as only 15 of our Autistic adolescents also had a comorbid diagnosis of Anxiety, but symptoms are likely present in a sufficient degree to show elevated levels on the CBCL.

Overall, the divergence in study outcomes provides as important information as the convergence of study outcomes. In tandem, elevated scores on Attention Problems, Social Problems, Withdrawn/Depressed Problems, and Thought Problems as a screener for ASD is supported by this additional study. Furthermore, this highlights the necessity for replication of studies to assemble a more cohesive understanding of outcomes and phenomenon at study. Further research should evaluate the correspondence of this pattern of elevation as predictive of outcomes of ASD diagnostic evaluations.

Results from our second aim, evaluation of PEERS® outcomes on the CBCL Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, and Social Problems scales, partially supported the hypothesis that those who received PEERS® would show decreases in scale mean scores. Decreases in the Withdrawn/Depressed and Social Problem mean scores over the course of PEERS®, evidenced only for the EXP group, supported our hypothesis. These findings are in line with previous research on PEERS®, showing increases in social ability, quality of interactions, and decreased depressive symptoms in adolescents that received the intervention (Authors., 2016a; Laugeson et al., 2012; Authors, 2017; Authors, 2014). Furthermore, decreased sensitivity in correct identification of Autism versus non-Autism (TD) group was shown to be present after intervention with the Social Problems scale no longer a significant predictor in the model. This is likely an effect of the robust effect of PEERS® on increasing social competency. Additionally, these findings hold implications for the utilization of the CBCL as an ASD screener for individuals who may have received some social skills training at a previous point in their life. Namely, the screener may be less sensitive to these individuals with prior training.

Conversely, no significant decreases were found in either group for the Anxious/Depressed scale; as thus, our hypothesis was partially not supported. Although prior research has shown decreases in social anxiety for adolescents who receive PEERS® (Authors, 2014), the findings may be linked to Anxious/Depressed scale items evaluating generalized anxiety rather than social anxiety specifically. Notably, previous PEERS® research has utilized the Social Anxiety Interaction Scale (SIAS; Mattick & Clarke, 1998). However, as the current study sought to examine the utility of the CBCL as a single outcome measure to examine symptoms change across PEERS®, the SIAS was not included in this study.

Limitations

It should be noted that there were several limitations to the present study. A prominent limitation to our study was the low inter-rater reliability found on the CBCL Somatic Complaints and Rule-Breaking Behavior scales precluding them from further analyses. Second, our sample of TD individuals was small in comparison to our ASD samples, and we did not have a non-ASD clinical comparison group. Future studies should utilize a larger TD and a clinical group sample to explore the sensitivity and specificity conferred by utilizing a certain elevation pattern on CBCL as a screening measure for ASD. Third, as a parent-report, the CBCL may have biased responding due to parent involvement in the PEERS® program (Laugeson et al., 2009). Fourth, our samples consisted of mostly White Caucasian males, and as such may only represent the feasibility of the CBCL as an ASD screener for White males, particularly considering emerging research on the Female Autism Phenotype (Hull et al., 2020). Future studies should evaluate ASD CBCL subscale elevation pattern, as well as PEERS® outcomes on the CBCL subscales, in a more diverse group to examine for effects of sex, race, and/or ethnicity.

Conclusion

In sum, results from the present study further support existing research examining a specific pattern of subscale elevation on the CBCL to utilize as a screener for ASD, and supports previous research showing efficacy of the PEERS® intervention in reducing social challenges and depressive symptoms. Specifically, elevated mean scores and high percentage of Autistic adolescents reported at or above the borderline clinical level of symptom endorsement on the Anxious/Depressed, Withdrawn/Depressed, Social Problems, Thought Problems, and Attention Problems subscales were found. Given the common comorbid symptoms (regardless of a formal comorbid diagnosis) found in ASD, this pattern is not surprising, as it is likely capturing both ASD core symptoms via the Social Problems and Thought Problems subscales, and additional anxious, depressive, and attention challenges often found in ASD via the remaining scales. As ASD + comorbidities have been shown to increase overall challenges to an individual’s life (e.g., quantity and quality of friendships) above and beyond ASD only (Bellani et al., 2013; Chang et al., 2012; Holtmann et al., 2007; Mazurek & Kanne, 2010; Sikora et al., 2012; White & Roberson-Nay, 2009) the CBCL may provide a unique manner in which to screen for children at high-risk for ASD and its comorbidities in a single questionnaire. Furthermore, this holds implications for schools and general healthcare settings that have low and limited resources. The ability to potentially use a broadband measure that can be used to screen for emotional and behavioral problems, and as an ASD screener lowers the resource cost to these institutions; therefore, increasing accessibility for the community. Future research is, however, necessitated to continue the evaluation of the validity of the CBCL as a screening measure for ASD. Furthermore, future research should compare CBCL screening validity and reliability compared to other screeners (e.g., Autism Spectrum Screening Questionnaire; Ehlers et al., 1999).

Supplementary Material

Supplementary Material

Figure 1.

Figure 1.

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CONSORT DIAGRAM

Table 3.

Percent of adolescents at or above the Borderline Clinical Range for the CBCL Syndrome Scale

Scale ASD Samples %
(N=109)		 TD Sample %
(N=46)
Anxious/Depressed 51.4 6.5
Withdrawn/Depressed 56.0 2.2
Social Problems 63.3 4.3
Thought Problems 70.6 8.7
Attention Problems 51.4 0.0
Aggressive Behavior 22.9 4.3
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Acknowledgements:

The authors would like to thank both the adolescents, and their families, who participated in this study. The authors would also like to thank all present and prior Marquette Autism Program research team members whose continual effort makes work like this possible.

Footnotes

Conflict of Interests: Alexis A. Arias, Madison Rea, Elyse J. Adler, Angela D. Haendel, and Amy Vaughan Van Hecke declare they have no conflict of interest.

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