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CBCL Profiles of Children and

Adolescents with Asperger Syndrome:


AReview and Pilot Study

Abstract
Volume 17, Number 1, 2011
There is increasing recognition of psychiatric co-morbidities in
individuals with Asperger syndrome (AS) that extend beyond
the core features of the disorder. Previous research with indi-
Authors viduals with AS and autism are summarized. This study aims
to examine the behavioural profile of a non-referred AS sample.
Jessica Schroeder, The Childhood Behaviour Checklist (CBCL) was completed
Jonathan Weiss, by parents of fifteen children and adolescents with AS (618
James Bebko years). Elevated scores across all CBCL scales were found
relative to the normative group. Social, thought and attention
Department of Psychology, problems and anxiety and depressive symptoms were particu-
York University, larly elevated. Research and clinical implications are discussed.
Toronto, ON
Asperger syndrome (AS) is a pervasive developmental dis-
order on the autism spectrum. It is similar to autistic dis
order (AD) in that a diagnosis requires two social symptoms
and one behavioural symptom. However, according to the
Diagnostic and Statistical Manual-IV (DSM-IV), AS dif-
fers from AD in that there are no marked cognitive delays,
no clinically significant history of delays in language, cur-
rent communication deficits are not required, and there
is no upper limit on age of onset (American Psychiatric
Association [APA], 2000). While individuals with AD with
average or above average cognitive functioning (referred to
as high-functioning autism, HFA) also have no marked cog-
nitive delay and may have intact communication abilities,
the distinction between AS and HFA, according to DSM-IV
criteria, is based on the history of significant delays in lan-
Correspondence guage development for HFA, and the age of onset criterion,
although considerable debate exists about the ability to dif-
jessica4@yorku.ca ferentiate between the disorders (e.g., Mayes, Calhoun, &
Crites, 2001; Sciutto & Cantwell, 2005; Tryon, Mayes, Rhodes,
& Waldo, 2006). There is increasing recognition of psychi-
atric co-morbidities in individuals with autism spectrum
Keywords disorders (ASDs) beyond the core features of the disorders.
Several mental health problems are thought to be more com-
Asperger syndrome, mon than in the general population, although rates vary
CBCL, significantly depending on whether the sample is from the
psychopathology, community or psychiatric centre, the size of the sample, and
mood disorders, the disorders under examination. A review of the literature,
attention displayed in Table1, suggests high rates of anxiety disorders,
depression and attention problems in individuals with an
ASD, as well as the potential for symptoms of oppositional
defiant disorder and obsessive compulsive disorder.

Ontario Association on
Developmental Disabilities
CBCL of Children and Adolescents with AS
27
Table1: Summary of Research on Psychiatric Symptoms in Individuals with ASD

Comparison
Author Sample N AS group Measure Psychiatric symptoms
Brereton Clinical 381 No Intellectual DBC-P Attention-Autism>ID
et al., 2006 sample with disability Depression-Autism>ID
autism; 418
years Anxiety-Autism>ID

Gadow et al., Clinical 284 AS=80 Clinic CSI-4 Attention 60%


2005 sample with PDD- control, Depressive symptoms 6%
PDD; NOS=118 community-
612 years based TD Anxiety 24%
sample, Separation anxiety 7%
special Oppositional 27%;
education Conduct 7%
class
Gillott et al., Clinical 15 No Specific SCAS Anxiety-HFA>SLI
2001 sample with language Separation anxiety-HFA>SLI
HFA; impairment
812 years and TD Obsessive-Compulsive-
HFA>SLI
Hartley Clinical 169 No No CBCL Attention 39% Clinical range
et al., 2008 sample with Anxious/Depressed
autism; 4% Clinical range
1.55.8 years
Withdrawn 70% Clinical range
Aggression 23% Clinical range
Holtmann In or out 182 5 No CBCL Attention mean in Clinical
et al., 2007 patient with range
PDD; 320 Anxious/Depressed
years mean in Borderline range
Social Anxiety mean
in Clinical range
Withdrawn mean
in Borderline range
Thought mean in Clinical range
Hurtig et al., Clinical 47 AS=24 TD sample CBCL Withdrawn-AS/HFA>Control
2009 sample with HFA=23 YSR Social-AS/HFA>Control
HFA or AS;
1117 years TRF Thought-AS/HFA>Control
(girls)
Attention-AS/HFA>Control
(girls)
Kim et al., Clinical 59 19 No OCHS-R Attention 17%
2000 sample with Depression 17%
PDD;
914 years Anxiety 14%
Separation anxiety 9%
Oppositional 7%
Conduct 3%

continued on following page

v . 17 n .1
28 Schroeder et al.

Table1: Summary of Research on Psychiatric Symptoms in Individuals with ASD (continued)

Comparison
Author Sample N AS group Measure Psychiatric symptoms
Kobayashi & Clinical and 187 No No CBCL Depression common
Murata, 2003 community Obsessions common
sample with
autism;
young
adults
Leyfer et al., Community 109 No No ACI Attention 31%
2006 sample with Depression 10%
autism;
517 years Anxiety 2%
Phobia 44%
Separation anxiety 12%
Social phobia 8%
Oppositional 7%
Obsessive-Conduct 37%
Ming et al., Clinical 160 11 No MI Anxiety and depression 26%
2008 sample with Aggression 32%
ASD;
218 years
Shtayerman, Community 10 10 No PHQ-A Depression 20%
2007 sample with Anxiety 30%
AS; mean
age=20
years
Sukhodolsky Clinical trial 171 AS=6; No CASI Anxiety 9%
et al., 2008 participants PDD- Phobia 31%
with PDD & NOS=14
aggression Separation anxiety 11%
& SIB or Social phobia 20%
hyper-
activity;
517 years
Tonge et al., Clinical 127 52 No DBC Disruptive-AS>HFA
1999 sample with Antisocial-AS>HFA
HFA & AS;
418 years Social relating-AS>HFA
Anxiety-AS>HFA
Weisbrot et Clinical 483 AS=104; Clinical ECI-4 Anxiety-PDD>Clinical control
al., 2005 sample with PDD- control CSI-4
PDD; NOS=209
312 years
ACI=Autism Co-morbidity Index OCHS-R=Ontario Child Health Study-Revised
AS=Asperger syndrome PDD-NOS=Pervasive developmental disorder
CASI=Child and Adolescent Symptom Inventory not otherwise specified
CSI-4=Child Symptom Inventory PHQ-A=Patient Health Questionnaire-Adolescent
DBC=Developmental Behaviour Checklist SCAS=Spence Childrens Anxiety Scale
DBC-P=Developmental Behaviour Checklist-Parent SLI=Specific language impairment
ECI-4=Early Childhood Inventory-4 TD=Typically developing
HFA=High functioning autism TRF=Teacher Report Form
ID=Intellectual disability YSR=Youth Self Report
MI=Medical Interview

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CBCL of Children and Adolescents with AS
29
There is a paucity of research examining co- significant levels of anxiety, depression, and
occurring disorders in individuals specifically attention deficit hyperactivity disorder (ADHD),
with AS, independent of people with autism and somewhat lower levels for separation anxi-
(cf., Tantum, 2000). Most researchers describe ety (9%), oppositional behaviour (7%), and con-
their sample as autism spectrum disorder, duct problems (3%). In addition, they found
combining AS with autism (e.g., Holtmann, that internalizing problems were more com-
Bolte, & Poustka, 2007; Ming, Brimacombe, mon than externalizing problems, and noted
Chaaban, Zimmerman-Bier, & Wagner, 2008; that these disorders had detrimental effects on
Sukhodolsky et al., 2008), or excluding those the lives of the parents and children. Contrary
with AS altogether. This paper presents data to their hypotheses, these researchers did not
of a profile of mental health problems found find that verbal or non-verbal intelligence and
in individuals with AS using the Childhood specific autism symptoms were significant pre-
Behaviour Checklist (CBCL; Achenbach & dictors of anxiety or depression within their
Rescorla, 2000), a commonly used measure sample. They did find that discrepancies scores
within clinical settings. The pervasiveness of were significant, albeit very limited, predictors
co-occurring mental health issues in the ASD of mood problems, such that individuals with
population highlights the potential utility of substantially higher verbal than non-verbal
including a quick and easily administered intelligence reported higher levels of anxiety
screener to assessments. This study highlights and depression.
to clinicians and researchers the importance of
understanding the mental health problems that Hurtig and colleagues (2009) reviewed results
occur more frequently in this population. from the CBCL completed by parents of 47 ado-
lescents with AS or HFA. Similar to Kim and
Although limited, there is some research to colleagues (2000), no differences were found
suggest that those with AS experience more between the AS and the HFA groups; thus the
psychiatric problems than those with autism. groups were combined to create one AS/HFA
For example, Tonge, Brereton, Gray and Einfeld group. They found that 54% of CBCL Total
(1999) report that 85% of their AS sample met Problems scores were in the Borderline range
criteria for at least one additional disorder, (82nd percentile) relative to less than 4% of the
relative to 65% of their autism sample. Parents typically developing (TD) comparison sample.
of children aged 418 years with AS reported Additionally, they found significantly higher
significantly more disruptive, antisocial, and scores on all Syndrome scales in the AS/HFA
anxious behaviours than those with autism. sample relative to the TD comparison adoles-
These results are consistent with research that cents. In this study, withdrawal, social problems,
demonstrates a negative relationship between attention and anxiety/depression scores were
autism symptoms and psychiatric problems particularly elevated in the AS/HFA sample rel-
in school-age children, with AS reporting ative to the TD comparison group. Gender dif-
more anxiety (Weisbrot, Gadow, DeVincent, ferences within groups were found and no other
& Pomeroy, 2005) and psychiatric problems sample characteristics were considered.
(Gadow, DeVincent, Pomeroy, & Azizian, 2005)
than those with a diagnosis either of autism, These variable results highlight the impor-
or Pervasive Developmental Disorder-Not tance of further investigation of psychiatric
Otherwise Specified (PDD-NOS). symptoms in individuals with AS. The CBCL
has previously been used to screen for mental
Other researchers have reported similar degrees health problems in individuals with autism.
of depressive and anxious symptoms in children Kobayashi and Murata (2003) had 187 parents
with AS and autism (Kim, Szatmari, Bryson, of adults diagnosed with autism complete the
Streiner, & Wilson, 2000). Kim and colleagues CBCL, and found elevated depression and
(2000) used the Ontario Child Health Study obsession symptoms. Although the CBCL was
(Boyle et al., 1987), which is based on questions modified for use with adults by changing the
from the CBCL, to assess mental health prob- wording of some items, the authors point out
lems in 59 children (9 14 years) with either HFA that their results may have underestimated the
or AS and found that, using normative cut-offs, occurrence of psychiatric symptoms given that
between 1417% of their sample had clinically the CBCL is intended for use with children and

v . 17 n .1
30 Schroeder et al.

may have overlooked symptoms more likely to 2) as a group, the AS sample will demonstrate
affect adults. Holtmann and colleagues (2007) overall higher rates of all symptoms relative
used the CBCL with 182 children and adoles- to the normative sample;
cents with ASD and analysed the Syndrome
scales. On average, Social, Attention and 3) Anxious/depressed, Attention, Social, and
Thought Problems were in the clinical range, Thought Problem syndrome scales will be
and Social Withdrawal, Anxiety/Depression, particularly elevated within the AS sample;
and Total Problems were in the borderline
range. Hartley and colleagues (2008) used the 4) Affective, Anxiety, and Attention Deficit/
CBCL with 169 young children (1.55.8 years) Hyperactivity DSM scales will be notably
with autism. One-third of their sample had high within the AS sample;
Total Problems scores in the clinical range,
with Withdrawal, Attention, and Aggression 5) Internalizing aggregate scores will be great-
the most frequently endorsed Syndrome scales. er than Externalizing score; and

The aim of the current study is to determine 6) correlations between sample characteristics
the frequency and severity of social, emotional, and CBCL scores will be non-significant.
and behavioural problems in a well-defined,
community sample of children and adolescents
with AS, using the CBCL. The CBCL is a wide- Methods
ly administered screener of psychopathology
used by many clinicians, and is often a part of Participants
a test battery of clinicians who work with chil-
dren with AS. Screening is an important and Fifteen children with AS between the ages of
easy first step in the detection of mental health 618 years participated in this study. Inclusion
problems in AS that may be overlooked due to criteria included no history of developmental
diagnostic overshadowing by their AS symp- language delay and average or above average
toms. At a basic level, the impairments in social cognitive and current language functioning.
interaction that characterize the disorder may Children were recruited through the Autism
well impact the persons social-emotional func- Spectrum Disorders-Canadian American
tioning, or vice versa. There are suggestions in Research Consortium registry and from agen-
the research literature, as well as in our clini- cies that serve families of individuals with
cal experience, of a possible profile of psycho- AS. Participants had a primary diagnosis of
pathology common to children with AS, with AS, which was confirmed through a review of
higher rates of internalizing behaviours than psychological reports using DSM-IV criteria
externalizing behaviours (e.g., anxiety vs. con- and by scores on the Krug Aspergers Disorder
duct disorder), as well as co-occurring attention Index (KADI; Krug & Arick, 2003). KADI stan-
problems, and social and thought problems dard scores ranged from 74114, comparable to
reflective of AS symptoms. Early detection the normative sample of individuals with AS
can inform early intervention to prevent these (M=100.27, SD=10.47). ADI-R scores were not
problems from escalating into psychiatric dis- used for confirmation of diagnosis because, as
orders in adulthood. noted by Autism Genetic Resource Exchange
(AGRE, n.d.), there is no validated algorithm
Correlation analyses examined the relations for identifying AS on the ADI-R. Scores for
among CBCL scores and other individual char- our group varied accordingly: 56% of the AS
acteristics of the participants, including intel- group scored in the autism range, 11% in the
ligence, language ability, and severity of ASD Not Quite Autism range, and 33% in the Broad
symptoms. The specific hypotheses of this Spectrum range.
study were:
Table2 displays sample characteristics includ-
1) the majority of individuals with AS in this ing age, IQ, language skill, and autism and AS
study will report at least one subscale within symptom severity.
the borderline or clinical ranges;

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CBCL of Children and Adolescents with AS
31
Table2: Sample Characteristics

N Mean SD Range
Age 15 12.07 2.86 616
FSIQ 15 115.40 15.19 89141
VIQ 15 116.47 16.61 88150
PIQ 15 111.47 13.99 86133
VIQ-PIQ 15 5.27 14.66 -1836
PPVT-III 15 113.73 21.19 80143

EOWPVT-2000 15 114.13 12.09 95141


KADI 15 100.67 9.57 74114
ADI-R 10 17.20 6.44 624
Social
ADI-R 10 12.70 6.73 521
Communication
ADI-R 10 6.00 2.63 311
Repetitive & Restricted Behaviour

ADI-R 10 2.50 1.35 04


Developmental History
FSIQ=Full-scale Intelligence Quotient; VIQ=Verbal Intelligence Quotient; PIQ=Performance Intelligence Quotient;
VIQPIQ=Verbal Intelligence Quotient minus Performance Intelligence Quotient; PPVT-III=Peabody Picture Vocabulary
Test-3rd Edition; EOWPVT-2000=Expressive One-Word Picture Vocabulary Test-2000 Edition; KADI=Krug Aspergers
Disorder Index; ADI-R=Autism Diagnostic Interview-Revised

Measures Anxious/depressed, Withdrawn/depressed,


and Somatic Complaints. Externalizing behav-
The Childhood Behavior Checklist (CBCL; iours tend to be directed outward, external to
Achenbach & Rescorla, 2000) was used to assess the individual. The Externalizing score compris-
behavioural, emotional, and social problems. es the Rule-breaking and Aggressive Behavior
It is a parent-report measure appropriate for Syndrome scales. Additional Syndrome scales
use with children aged 618 years with strong are Attention, Social, and Thought Problems.
empirically supported rating scales for assess- The DSM scales are: Affective, Anxiety, Somatic,
ing overall psychopathology, and with several Attention Deficit/Hyperactivity, Oppositional
syndrome subscales, developed using princi- Defiant, and Conduct Problems. T-scores are
pal components analysis. It is a 113-item ques- provided, with higher scores reflecting more
tionnaire that takes 1520 minutes to complete. problematic behaviour. A T-score of 50 repre-
Parents are asked to rate their child within sents the mean of the normative group with
the past 6 months using a three-point scale the standard deviation of 10. On syndrome and
(0=not true, 1=somewhat or sometimes true, DSM scales scores, T-scores of 6569 represent
and 2 = very true or often true). Scores for the borderline range (93rd to 97th percentile), and
Internalizing, Externalizing and Total Problems T-scores above 70 fall into the clinical range
are provided, along with several subscale scores. (above the 97th percentile). For aggregate and
Internalizing behaviours occur within the self Total Problems scores, the borderline range is
and represent an over-controlled or inhibited defined by T-scores in the 6063 range (84th to
pattern of behaviors. The Internalizing score 90th percentile) and T-scores above 63 are in the
comprises the following syndrome scales: clinical range. Extensive reliability and validity

v . 17 n .1
32 Schroeder et al.

data are reported in the manual (Achenbach, General Procedure


1991) and reviews indicate strong overall psy-
chometric properties (Flanagan & Watson, 2005). This study was reviewed and approved by the
Office of Research Ethics at York University. The
Cognitive and language functioning data reported in the paper were obtained as part
of a larger experimental procedure. Participants
The Wechsler Abbreviated Scale of Intelligence completed two experimental tasks that involved
(WASI; The Psychological Corporation, 1999) presentation of auditory and visual stimuli on a
was used as a brief estimate of intellectual large screen, which required 14 minutes to com-
skills, and yielded a Verbal IQ, Performance IQ, plete, and are not reported here. After a brief
and Full Scale IQ score. The WASI was selected break, children were assessed using the WASI,
because the administration time is approxi- the PPVT-III, and the EOWPVT-2000, lasting
mately 30 minutes and it is rated as having approximately 1.01.5 hours in total. During
very strong psychometric properties overall, the experiment, parents were asked to complete
its Full Scale IQ score correlating .81 and .87, the CBCL, the KADI, and an optional measure
respectively, with the full scale IQ scores of the of ASD symptoms that was in the process of
two measures from which it was derived, the becoming standardized.
Wechsler Intelligence Scale for Children-III and
the Wechsler Adult Intelligence Scale-III, and Analyses
with similar correlations for the subscales (e.g.,
Keith, Lindskog, & Smith, 2001; Sattler, 2001; A series of one-sample t-tests were calculated to
The Psychological Corporation, 1999). compare the AS groups mean CBCL syndrome
scores to a T-score of 50, indicative of the mean
The Peabody Picture Vocabulary TestIII (PPVTIII; for the typically developing normative group.
Dunn & Dunn, 1997) was used as a screening Due to the large number of comparisons, alpha
test of single-word listening comprehension. was set to .01. Descriptive analyses were also
conducted to determine what percentage of
The Expressive One-Word Picture Vocabulary participants fell into the borderline and clinical
Test2000 Edition (EOWPVT-2000; Brownell, ranges. A paired-sample t-test was conducted
2000) was used as a measure of expressive one- to determine differences between internalizing
word vocabulary. and externalizing behaviour within the sample.
Post hoc contrasts were used to determine dif-
ASD measures ference among symptom scales. Correlational
analyses were conducted to determine the rela-
Autism Diagnostic Interview Revised (ADI-R; tions among age, language ability (PPVT-III
Lord, Rutter, & LeCouteur, 1994) is a standard- and EOWPVT-2000 scores), intelligence (WASI
ized, semi-structured clinical review for care- FSIQ, VIQ, and PIQ scores and VIQ/PIQ split),
givers of children and adults. It was admin- symptom severity (KADI and ADI-R scores),
istered to parents to identify the severity of and CBCL Internalizing, Externalizing, and
symptoms reported for participants using the Total scores.
AGRE affective status categories.

The Krug Aspergers Disorder Index (KADI; Krug Results


& Arick, 2003) is a parent-report scale that indi-
cates the presence or absence of behaviours As shown in Table3, all symptom scores were
that are indicative of AS. It is used to identify significantly greater than the normative sam-
those with AS and to discriminate between AS ple mean. Overall, the Anxiety/depression,
and high functioning autism. It was used to aid Social Problems, Thought Problems, Attention
in the confirmation of AS diagnosis. In a review Problems Syndrome scales, and the Anxiety,
of five diagnostic tools for AS (Campbell, 2005), DSM-IV scale, were found to have a mean in
the KADI had the strongest psychometric the borderline range. In addition, the mean
properties. Internalizing and Total problems scores were
found to be in the clinical range. Significance

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CBCL of Children and Adolescents with AS
33
levels were such that even conservative correc- demonstrates the groups AS symptom profile,
tions for the multiple t-tests still indicated sig- through boxplot analyses. The degree of vari-
nificant differences. ability and presence of outliers should be con-
sidered when interpreting the results.
All participants had at least one score in the
borderline range, and eighty percent of par- The paired-sample t-test revealed a trend
ticipants had at least one symptom score in towards a difference between internalizing
the clinical range. Sixty-seven percent of par- behaviour and externalizing behaviour scores,
ticipants showed a Total Problems score in the t(14)=2.39, p=.03 (significant at the alpha=.05
clinical range. The scales most commonly in level, but not at the adjusted alpha of .01), with
the borderline or clinical range in this sam- the AS group showing significantly higher
ple were: Thought Problems (80%), Anxiety levels of internalizing problems. Post hoc con-
Problems (67%), Anxious/Depressed (67%), trasts with Sidak-Bonferroni adjustment con-
Attention Problems (63%), and Social Problems firmed that there were significant differences
(60%; see the first column of Table3). Figure1 among the symptom scales, with greater sever-

Table3: Mean T-scores of AS Participants on CBCL Syndrome and DSM-IV Scales

% Mean
Scale Clinical (SD) t(df) p-value Cohens d

Syndrome scales
Anxious/depressed 20 (47) 66.13 (8.54) 7.31 (14) <.001 1.73
Withdrawn/depressed 13 (20) 62.40 (10.68) 4.49 (14) .001 1.19
Somatic complaints 6 (13) 59.60 (6.81) 5.46 (14) <.001 1.12
Social problems 40 (20) 65.87 (8.35) 7.36 (14) <.001 1.72
Thought problems 47 (33) 68.87 (7.53) 9.70 (14) <.001 2.13
Attention problems 30 (33) 66.73 (7.98) 8.12 (14) <.001 1.85
Rule-breaking behaviour 13 (0) 56.33 (7.29) 3.36 (14) .005 0.72
Aggressive behaviour 13 (30) 61.93 (10.69) 4.33 (14) .001 1.15

DSM scales
Affective problems 13 (33) 64.87 (10.95) 5.26 (14) <.001 1.42
Anxiety problems 20 (47) 66.33 (7.74) 8.17 (14) <.001 1.83
Somatic problems 20 (0) 57.13 (6.48) 4.26 (14) .001 0.85
ADHD problems 40 (20) 64.80 (7.27) 7.88 (14) <.001 1.69
ODD problems 27 (13) 61.07 (8.15) 5.26 (14) <.001 1.21
Conduct problems 13 (13) 59.00 (10.17) 3.43 (14) .004 0.89

Aggregate scores
Internalizing 53 (13) 65.33 (7.42) 8.00 (14) <.001 1.74
Externalizing 20 (33) 58.47 (10.11) 3.24 (14) .006 0.84
Total problems 67 (13) 65.73 (7.24) 8.42 (14) <.001 1.80
ADHD=attention deficit hyperactivity disorder; ODD=oppositional defiant disorder
Note: scores of 6569 are in the Borderline range, indicating elevated risk for that variable; scores>70 are considered as likely in
the Clinical range. For the aggregate scores, scores of 6063 are in the Borderline Range, and scores64 are in the Clinical range.
A Cohens d of 0.2 is considered a small effect size, 0.5 is medium, and>0.8 is considered a large effect size.

v . 17 n .1
34 Schroeder et al.

100

90

80
T-Score

70

60

50
Anxiety/Depression

Withdrawn/Depression

Somatic Complaints

Social

Thought

Attention

Rule-Breaking

Aggression

Affective

Anxiety

Somatic Problems

ADHD

ODD

Conduct

Figure 1. Boxplots of syndrome and DSM-IV scales


Note: vertical line=range; box=middle 50% of scores; line in box=median; *=major outliers; =minor outliers

ity of Thought symptoms and Attention symp- Discussion


toms relative to the severity of Rule-breaking
symptoms, M=12.3, p=.001 and M=10.4, These results indicate that on average, parents
p=.003, respectively. No other significant dif- of individuals with AS reported significantly
ferences based on symptom severity on the higher symptom severity on every scale of the
CBCL emerged. CBCL relative to the norming population, thus
supporting the first and second hypotheses.
Correlational analyses indicated no significant Sixty-seven percent of participants showed
correlations among any of the demographic a total problems score in the clinical range,
variables (age, language ability, intelligence, and all participants had at least one scale that
age, autism symptom severity) and the CBCL fell one and a half standard deviation points
Internalizing, Externalizing or Total Problems above the population average. This is consis-
scales (all p.14). tent with Tonge and colleagues (1999), who
reported that 85% of their AS sample met cri-
teria for at least one disorder. As predicted in

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CBCL of Children and Adolescents with AS
35
the third and fourth hypotheses, the scales that ties and from other people. Withdrawal charac-
were most commonly endorsed in the sample terizes autism more severely, and each of those
were Thought, Anxiety, Social, Affective, and studies used mixed diagnostic samples, com-
Attention Problems. These results are consistent pared to our sample, which was limited to AS.
with the current literature on AS and anxiety, In AS, unsuccessful attempts at social approach
depression, and obsessions (Gadow et al., 2005; are more common than withdrawal.
Hartley et al., 2008; Hurtig et al., 2009; Kim et
al., 2000; Kobayashi & Murata, 2003; Tonge et Hurtig and colleagues (2009) were unique in not
al., 1999; Weisbrot et al., 2005). Consistent with finding thought problems to be as problematic in
our fifth hypothesis, the results indicate that their sample; however, they removed three items
using the CBCL, internalizing behaviour is sig- from the thought problems subscale due to over-
nificantly more problematic than externalizing lap with autism symptomatology. The Hartley
behaviour. Individuals with AS also appear at and colleagues (2008) study was also unique in
significant risk for associated thought prob- that aggression was frequently endorsed relative
lems, anxiety and depression, social problems, to other scales. This may be related to the age
and attention problems, and it is important to of their sample (1.55.8 years); it is possible that
further investigate these linkages. The sixth aggression is more frequently noted in younger
hypothesis regarding correlations between children with autism than older children with
autism, or individuals with AS.
sample characteristics and CBCL scores was
also supported. Consistent with Kim and col-
Thought problems (including obsessive thoughts
leagues (2000), intelligence, language ability,
and repetitive actions) and social problems as
and autism symptoms were not significantly
measured by the CBCL may overlap with sev-
correlated with CBCL scores. This is not sur-
eral of the central diagnostic features of AS,
prising given the homogeneity of these scores
including repetitive and restricted behaviours
within the sample and the small sample size.
and social difficulties (Hurtig et al., 2009). Future
research is needed to determine if these prob-
Our AS samples CBCL profile is consistent with lems may be indicative of co-occurring OCD
the profile found in the Pervasive Developmental or psychotic symptoms, or simply part of the
Disorder (PDD) group examined by Holtmann expression of ASD. More distinct from ASD
and colleagues (2007), with a few notable and symptoms, however, are attention problems,
predictable exceptions. Across scales, the means anxiety, and depression, which are not consid-
for our AS sample were somewhat lower than ered core features of AS, and elevated scores in
for the Holtmann et al. PDD group. This may these domains are likely more indicative of co-
suggest that the AS group showed less psycho- morbidity. Attention problems frequently occur
pathology than the PDD group in their study, in individuals with ASD, although these features
although theirs was a mixed sample. It is more are not considered core to the disorder. While
likely that the means from our sample underes- the DSM-IV prohibits the diagnosis of ADHD
timate the actual symptom severity of the sam- in individuals with PDD, due to overlap in diag-
ple. The frequency of reported symptoms that nostic features, some clinicians will diagnose
fell into the borderline and clinical ranges in our ADHD in individuals with PDD. A more criti-
sample was quite high, and the group means cal question that could be addressed in future
were reduced by the small number of scores in research is at what point should the core charac-
the non-clinical range. teristics of AS perhaps be expanded to recognize
that the majority of individuals with ASD expe-
The symptoms that emerged as being particu- rience these issues. Additional research might
larly problematic in both the Holtmann and also include information from multiple sources,
colleagues (2007) PDD sample, and the Hurtig such as teachers, as parents may tend to under-
et al. (2009) AS plus HFA sample included report psychiatric symptoms in their children,
withdrawal, social problems, attention, and and an additional rating source would help pro-
anxiety/depression. Hartley and colleagues vide additional confidence in interpretation of
(2008) also found withdrawal to be particularly reported symptoms. If it is the case that parents
problematic in their sample of young children were under-reporting, then the present results
with autism. These differences are quite consis- may actually be an underestimation of existing
tent with our findings, except for withdrawal, problems in the population.
which comprises both withdrawal from activi-

v . 17 n .1
36 Schroeder et al.

While the small sample size, reliance on parent American Psychiatric Association. (2000).
report only and lack of an autism or typically Diagnostic and statistical manual of mental
developing comparison groups may be limiting disorders (4th ed., text rev.). Washington,
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lights the importance of considering co-mor- Boyle, M. H., Offord, D. R., Hofmann, H. G.,
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treatments for mental health problems in indi- adolescents with autism compared to
viduals with AS. Finally, additional research young people with intellectual disability.
is warranted to determine if there are specific Journal of Autism and Developmental
early symptoms of AS that predict later behav- Disorders, 36, 849861.
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