DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Emotional and behavioural problems in young children with

autism spectrum disorder
SUSIE CHANDLER 1,2 | PATRICIA HOWLIN 2,3 | EMILY SIMONOFF 2,4 | TONY O’SULLIVAN 5 | EVELIN TSENG 6 |
JULIET KENNEDY 7 | TONY CHARMAN 2 | GILLIAN BAIRD 1

1 Paediatric Neurosciences, Newcomen Centre, Guy’s & St Thomas’ NHS Foundation Trust, King’s Health Partners, London; 2 Institute of Psychiatry, Psychology &
Neuroscience, King’s College London, London, UK. 3 Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia. 4 National Institute for Health
Research (NIHR) Biomedical Research Centre for Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London; 5 Kaleidoscope –
Lewisham Centre for Children and Young People, Lewisham & Greenwich NHS Trust, London; 6 Bromley Healthcare CIC Ltd, London; 7 The Nuffield Orthopaedic
Centre, Oxford University Hospitals NHS Trust, Oxford, UK.
Correspondence to Gillian Baird at Children’s Neurosciences Centre, Block D, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK. E-mail: gillian.baird@gstt.nhs.uk

This article is commented on by Smith on pages 121–122 of this issue.

PUBLICATION DATA AIM To assess the frequency, pervasiveness, associated features, and persistence of
Accepted for publication 18th May 2015. emotional and behavioural problems in a community sample of young children with autism
Published online 16th June 2015. spectrum disorder (ASD).
METHOD Parents (n=277) and teachers (n=228) of 4- to 8-year-olds completed the
ABBREVIATIONS Developmental Behaviour Checklist (DBC). Intellectual ability and autism symptomatology
ASD Autism spectrum disorder were also assessed. A subsample repeated the DBC.
DBC Developmental Behaviour RESULTS Three-quarters of the cohort scored above the clinical cut-off on the Developmental
Checklist Behaviour Checklist Primary Carer Version (DBC-P) questionnaire; almost two-thirds of these
DBC-P Developmental Behaviour scored above cut-off on the Developmental Behaviour Checklist Teacher Version (DBC-T)
Checklist Primary Carer Version questionnaire. In 81%, problems persisted above threshold 14 months later. Higher DBC-P scores
DBC-T Developmental Behaviour were associated with greater autism symptomatology, higher deprivation index, parental
Checklist Teacher Version unemployment, and more children in the home but not with parental education or ethnicity, or
SCQ Social Communication Ques- child’s age or sex. Children with IQ>70 scored higher for disruptive behaviour, depression, and
tionnaire anxiety symptoms; those with IQ<70 scored higher for self-absorption and hyperactivity.
INTERPRETATION The DBC identifies a range of additional behaviour problems that are
common in ASD and which could be the focus for specific intervention. The results highlight
the potential benefit of systematic screening for co-existing problems.

Autism spectrum disorder (ASD) is a neurodevelopmental
disorder characterized by impairments in reciprocal social
interaction, communication, and repetitive, stereotyped
interests and behaviours.1 Recent estimates suggest a prev-
alence rate of over 1%.2 ASD is associated with high co-
morbidity and significant costs to individuals, families,
and services.3 Emotional and behavioural problems in
ASD are frequent,4 and rates of social anxiety, attention-
deficit–hyperactivity disorder and oppositional disorder are
elevated compared both with the general population5 and
with children with intellectual disability.6–8 Functional
problems in sleeping, eating, and toileting are also
increased. High rates of behavioural and emotional distur-
bance are evident from pre-school onwards9 and many
children have two or more comorbid problems.10,11 In
non-ASD populations with and without intellectual disabil-
ity, prevalence and types of emotional and behavioural dif-
ficulties are associated with age, sex, IQ, ethnic group, and
social disadvantage.5,7 In ASD these factors are less clearly
linked to psychiatric co-morbidity6,11 although the type of
difficulty does vary with IQ, age, and sex.6 Psychiatric
disorders also have a high prevalence in adults12 and,
together with functional problems, can have as great an
adverse impact as core ASD symptoms. There is, neverthe-
less, a range of evidence-based interventions that could
reduce the effects of these problems.13 Hence systematic
assessment of emotional/behavioural difficulties by clini-
cians is crucial. This paper describes the use of parent and
teacher questionnaires to assess comorbid emotional and
behavioural problems in a community sample of young
children (age 4–9y) with ASD.
METHOD
The study was approved by Guy’s Hospital Research Eth-
ics Committee (08/H0804/37) and Bromley and Lewisham
Local Research Ethics Committees (RDLEWBR 428).
Recruitment procedures
The target population comprised all children born between
1 September 2000 and 1 September 2004 (aged 4–8y at

202 DOI: 10.1111/dmcn.12830 © 2015 Mac Keith Press

time of recruitment) with a diagnosis of ASD made by the
local multidisciplinary teams and living in two London
boroughs with a broad range of socio-economic circum-
stances and ethnic backgrounds. In both boroughs,
children suspected of having ASD receive a neurodevelop-
mental assessment from the community paediatrician. A
few are diagnosed at this appointment but most are
referred onto the multidisciplinary communication clinic.
After a speech and language assessment and report from
nursery/school, children then attend the multidisciplinary
clinic consisting of a paediatrician, a speech and language
therapist, or psychologist for a formal assessment of
features specific to ASD. Measures include the Autism
Diagnostic Interview-Revised,14 Developmental, Diagnos-
tic and Dimensional Interview,15 Diagnostic Interview for
Social Communication Disorder,16 or local pro forma and
the Autism Diagnostic Observation Schedule.17
Eligible families (n=447) were mailed invitations to par-
ticipate together with consent forms. Consenting families
were mailed the questionnaire pack. Non-responders were
telephoned and re-mailed. If they still failed to respond,
researchers telephoned again and offered to re-mail the
questionnaires or complete them with parents over the
telephone or at home. To assess pervasiveness of problems,
teachers were asked to complete the teacher version of the
questionnaire. To assess the persistence of difficulties a
subset of parents completed the questionnaire on two occa-
sions (times 1 and 2). For the assessment at time 2, females
were over-sampled to provide adequate numbers for analy-
sis (further details in Appendix S1, online supporting infor-
mation).
Measures
Emotional and behaviour problems
A focus group of eight parents with children with ASD
aged younger than 10 years was recruited to determine
which of several questionnaires, commonly used in clinical
practice in the UK, best described their child’s emotional
and/or behavioural problems and was most acceptable to
them (details in Appendix S2, online supporting informa-
tion). The Developmental Behaviour Checklist (DBC18)
was selected as the preferred instrument for the study. Par-
ents rated it positively in terms of acceptability, ease of
use, clarity of questions, scoring, and range of questions,
and there are parallel parent and teacher versions that
allow assessment of problems across settings.
The DBC Primary Carer Version (DBC-P) is a 96-item
behaviour checklist covering a broad range of behaviours,
each rated as 0 (‘not true as far as I know’), 1 (‘somewhat
or sometimes true’), or 2 (‘very or often true’). It has satis-
factory internal consistency, interrater and test–retest reli-
ability, and concurrent validity with other psychopathology
measures, particularly in samples of children and adoles-
cents with intellectual disability.19,20 The DBC has five
empirically derived subscales (Disruptive/Antisocial; Self-
absorbed; Communication Disturbance; Anxiety; Social-
relating), and four scales that can be used to identify
What this paper adds
• Three-quarters of 4- to 8-year-olds with autism have parent-reported emo-
tional and behavioural problems.
• Two-thirds of these also have teacher-reported problems.
• Problems persist over time in 80%, and identification is possible at 4 to
5 years.
• The Developmental Behaviour Checklist assesses a wide range of difficulties
in children with autism spectrum disorder (ASD).
• Systematic use of such a questionnaire is recommended in routine clinical
care of children with ASD.
specific psychiatric syndromes (Autism Screening Algo-
rithm; Depression scale; Hyperactivity scale, and Anxious
Behaviour Rating Scale). The total behaviour problem
score (range 0–192) indicates overall level of disturbance; a
cut-off score of at least 46 is recommended for identifying
clinically significant emotional and/or behavioural prob-
lems. The DBC Teacher Version (DBC-T) has 94 items; a
total score of at least 30 is recommended as the cut-off for
identifying caseness.
Autism symptomatology
Autism symptomatology was measured using the parent-
rated Social Communication Questionnaire Lifetime
version (SCQ).21 It comprises 39 items scored 0 or 1; a
cut-off of more than 15 is recommended for identifying
potential cases of ASD.
Demographic characteristics
Demographic characteristics were collected by means of a
parent questionnaire. Postcode data were used to access a
deprivation index (The English Indices of Deprivation
2007),22 which ranks small geographical areas across Eng-
land according to deprivation level, based on income, edu-
cation, employment, and living environment (a higher
index score means greater deprivation).
Child assessments
IQ was measured by the research team, trained and experi-
enced in psychometric assessments, using either the
Wechsler Intelligence Scale for Children,23 Wechsler Pre-
school and Primary Scale of Intelligence,24 or Mullen
Scales of Early Learning25 depending on chronological age
and developmental level (Appendix S2). Parents were also
asked, ‘At what age do you think your child is functioning
overall?’. The British Picture Vocabulary Scale26 was used
to measure receptive language for children who had suffi-
cient language to access the test.
Data analysis
Statistical analyses used STATA 11 (StatCorp, College Sta-
tion, TX, USA, 2009). For some analyses IQ was treated
as continuous and for others as a dichotomous variable
(<70/>70). For sleeping, eating, and toileting problems, the
‘somewhat’/’sometimes’ and ‘very often’/’often’ categories
of the DBC were combined to create a dichotomous score.
Associations between DBC-P/T scores and background
factors (number of children at home; parent education,
Emotional and Behavioural Problems in ASD Susie Chandler et al. 203
employment, and ethnicity) were examined using multiple
linear regression. Multinomial logistic regression was used
to explore factors associated with discrepancies (i.e. above/
below clinical cut-off) between primary carer (hereafter
referred to as parent) and teacher questionnaires, and to
explore factors associated with changes in parent question-
naires (i.e. above/below clinical cut off) at times 1 and 2
(see Appendix S1 for full details).
RESULTS
Participant characteristics
Responses were received from 362 of 447 (81%) families
(see Figure S1, online supporting information). Parental
questionnaires were completed on 277 children (62%), half
by post, the remainder by telephone or home visit. Non-
participating families had a higher mean deprivation index
(t[443])=3.39, p<0.001) and contained a higher proportion
of males (v2[1, n=447]=5.36, p=0.021) (see Appendix S3,
online supporting information, for details of participants
and non-participants at initial assessment). Mean age of
child participants at recruitment was 6 years (SD 1y 1mo)
and at first assessment 6 years 10 months (SD 1y 2mo).
Most (77%, n=214) attended mainstream school; 44
attended special schools; 15 attended special units within
mainstream schools; three were home-schooled; one
attended mainstream nursery. The clinical records of any
child with a low score on the SCQ score (i.e. total <10;
n=28) were checked with local clinicians; diagnosis was
confirmed in all cases and none was excluded from the
sample.
Cognitive assessments were completed for 258 children.
Full-scale IQ scores were calculated for 211 (67 on the
Wechsler Intelligence Scale for Children;23 144 on the
Wechsler Preschool and Primary Scale of Intelligence24).
For children tested on the Mullen Scales of Early Learn-
ing,25 the composite standard score was used when possible
(n=13); for those above the Mullen Scales of Early Learn-
ing age range (n=34), age-equivalents were used to derive a
ratio IQ. Those with a Mullen Scales of Early Learning
ratio IQ<20 (n=11) were assigned an IQ of 19 to reflect
their very low ability. Parental estimates of functional age
were also used to generate a parent-estimated developmen-
tal quotient for 15 children (details in Appendix S4, online
supporting information). The mean IQ estimate for the
sample was 72.7; 35% had an IQ<70; 21.6% had an
IQ<50. Missing cognitive data were because of lack of
parental consent or child compliance issues.
DBC-P scores are presented in Table I. The internal
consistency of each of the subscales (Disruptive/Antisocial,
Self-absorbed, Communication Disturbance, Anxiety,
Social Relating), the Autism Screening Algorithm, Depres-
sion and Hyperactivity scales, and Anxious Behaviour

Table I: Mean DBC-P and DBC-T scores by IQ group and sex

IQ<70 (n=96) IQ≥70a (n=177) Males (n=227) Females (n=50) Total sample (n=277)

Mean scores (SD)

DBC-P
Total behaviour problem score 72.3 (24.8) 70.2 (32.1) 71.6 (30.4) 69.1 (25.6) 71.2 (29.6)
Disruptive/Antisocial 19.5 (9.1)b 23.2 (11.4)b 22.1 (11.0) 21.5 (10.0) 22.0 (10.8)
Self-absorbed 27.4 (11.5)c 19.9 (11.5)c 22.8 (12.2) 21.8 (11.4) 22.6 (12.0)
Communication disturbance 10.6 (4.7) 11.1 (5.1) 11.2 (5.1) 10 (4.6) 11.0 (5.0)
Anxiety 7.2 (3.5) 8.2 (4.5) 7.8 (4.2) 8.0 (4.0) 7.8 (4.2)
Social relating 6.7 (2.8) 6.0 (3.3) 6.3 (3.3) 6.1 (2.9) 6.3 (3.2)
Autism screening algorithm 31.0 (9.8)c 25.8 (11.4)c 28.1 (11.3) 26.5 (10.4) 27.8 (11.1)
Depression scale 5.2 (3.1)b 6.4 (3.8)b 6.0 (3.7) 6.1 (3.0) 6.0 (3.6)
Hyperactivity scale 8.3 (2.8)b 7.4 (3.3)b 7.8 (3.2) 7.3 (2.8) 7.7 (3.1)
Anxious Behaviour Rating Scale 5.1 (3.1)b 6.3 (3.6)b 5.9 (3.5) 5.9 (3.6) 5.9 (3.5)
Sleeps too little/disrupted sleep (%) 59.6 57.1 57.8 62.0 58.6
Has nightmares/night terrors/sleepwalks (%) 27.1b 45.5b 27.1 45.8 39.7
Fussy eater/has food fads (%) 66.7 71.0 69.0 72.0 69.6
Gorges on food (%) 31.3b 18.6b 22.9 24.0 23.1
Urinates outside the toilet (%) 39.6 32.2 36.1 26.0 34.3
Soils outside the toilet/smears (%) 39.6c 15.8c 25.1 20.0 24.2
DBC-T
Total behaviour problem score 45.7 (18.4)c 34.0 (21.4)c 38.6 (20.2) 36.2 (24.6) 38.1 (21.1)
Disruptive/Antisocial 11.8 (7.2) 11.3 (8.9) 11.5 (8.4) 11.1 (8.4) 11.4 (8.3)
Self-absorbed 17.3 (8.9)c 9.0 (7.5)c 12.1 (8.4) 11.3 (10.8) 12.0 (8.9)
Communication disturbance 6.7 (3.9)c 4.5 (3.7)c 5.5 (3.9) 4.5 (4.1) 5.3 (3.9)
Anxiety 3.8 (2.5) 3.2 (2.7) 3.3 (2.6) 4.0 (2.8) 3.4 (2.6)
Social relating 5.9 (3.3)b 4.4 (3.3)b 5.0 (3.4) 4.3 (3.4) 4.9 (3.4)
Autism screening algorithm 20.7 (9.0)c 12.6 (8.9)c 15.7 (9.2) 14.6 (11.8) 15.5 (9.8)
Depression scale 2.9 (2.2) 3.1 (2.5) 2.9 (2.4) 3.6 (2.5) 3.0 (2.4)
Hyperactivity scale 6.0 (3.1)c 4.5 (3.4)c 5.2 (3.3) 4.2 (3.4) 5.0 (3.4)
Anxious Behaviour Rating Scale 2.7 (2.3) 2.8 (2.5) 2.7 (2.3) 3.3 (2.6) 2.8 (2.4)
a
Total n with IQ data=273 (four cases missing IQ data). bStudent’s t-test (means comparison) or v2 (% comparison), p<0.05. cStudent’s t-test
(means comparison) or v2 (% comparison), p<0.001. DBC-P, Developmental Behaviour Checklist Primary Carer Version; DBC-T, Develop-
mental Behaviour Checklist Teacher Version.

204 Developmental Medicine & Child Neurology 2016, 58: 202–208

Rating Scale was good to excellent (Chronbach’s a range Table II: DBC-P and DBC-T total scores: Pearsons correlations with age,
0.66–0.91, mean 0.80). Mean total behaviour problem IQ, SCQ, deprivation index, and regression analysis for effect of
score was 71.2 (SD 29.6); 79% scored above cut-off (95% background factors
at age 4; 83% at age 5; 76% at age 6; 75% at age 7; 80%
at age 8), significantly higher than the 41% who scored n r value p value
above cut-off in the Australian normative intellectual dis- DBC-P total score with:
ability sample aged 4 to 8 years (Skuse et al.15) (p<0.001). BPVS standard score 209 0.05 0.83
Child’s age 277 0.02 0.75
There was no significant difference in total problems
SCQ total score 277 0.58 <0.0001
scores for children with IQ above or below 70 (t[271]= DBC-T total score 228 0.07 0.29
0.56, p=0.58) but there were some group differences in Deprivation index 227 0.13 0.01
DBC-T total score with:
subscale scores. Thus, children with IQ>70 scored higher
IQ 228 0.34 <0.0001
on the scales for Disruptive/Antisocial behaviour (t[271]= BPVS standard score 187 0.23 0.002
2.70, p=0.007), Depression (t[271]= 2.55, p=0.012), and Child’s age 228 0.03 0.67
SCQ total score 228 0.06 0.33
Anxious behaviour (t[271]=2.30, p=0.004). Children with
Deprivation index 228 0.02 0.08
IQ<70 scored more highly on the Self-absorbed (t[271]=
DBC-P total score (n=250) Coefficient (SE) t p value
2.70, p<0.001) and Hyperactivity scales (t[271]=2.30,
Parent education 3.03 (3.80) 0.80 0.42
p=0.022). Parent employment 13.29 (4.30) 3.09 0.002
Seventy per cent of the sample were reported to be fussy Ethnicity 0.006 (3.79) 0.00 0.999
Number of children 6.42 (2.25) 2.86 0.005
eaters/have food fads; disrupted sleep was reported in 59%
DBC-T total score (n=205)
and soiling/smearing in 24%. Soiling/smearing was more Parent education 2.47 (2.96) 0.84 0.41
common in younger children (i.e. <7y vs >7y, v2=3.84, Parent employment 1.15 (3.30) 0.35 0.73
Ethnicity 1.54 (2.91) 0.53 0.60
p=0.050); no other sleeping/eating/toileting problems were
Number of children 5.40 (1.75) 3.08 0.002
associated with age (all p>0.2). No significant sex differ-
ences were found between total or subscale scores (all DBC-P, Developmental Behaviour Checklist Primary Carer Version;
DBC-T, Developmental Behaviour Checklist Teacher Version; SCQ,
p>0.3). Social Communication Questionnaire; BPVS, British Picture Vocabu-
There was no correlation between total DBC-P score lary Scale.
and age, IQ, British Picture Vocabulary Scale standard
score, or sex (all correlations <0.10; see Table II). How- each case). Teachers rated children with IQ<70 as being
ever, there was a significant correlation with greater autism more self-absorbed (t[226]=7.48 p<0.001), and having more
symptoms on the SCQ (r=0.58; p<0.001), and with higher problems with communication (t[226]=4.22, p<0.001) and
deprivation index score (although the correlation was social-relating (t[226]=3.2, p=0.002) than those with IQ>70
small; r=0.15; p=0.01). Multiple regression also showed (see Table I). There was no significant relationship
DBC-P score to be associated with parental unemployment between IQ and DBC-T Disruptive/Antisocial or Anxiety
(b= 11.59 p=0.008) and more children in the home subscale scores (p=0.67 and 0.08 respectively). No sex dif-
(b=5.94, p=0.008). There was no association between ferences were found on DBC-T subscale scores (Student’s
DBC-P score and parental education (p=0.48) or ethnicity t-tests, all p>0.1).
(p=0.14). Unlike the parent ratings, total DBC-T score was nega-
Almost half (44%) the parents indicated that they had tively correlated with IQ (r= 0.34; p<0.001) and British
sought help for their child’s behaviour or emotional prob- Picture Vocabulary Scale standard scores (r= 0.23;
lems. Most (86%) of those who had sought help had chil- p=0.002) although these correlations were weak to moder-
dren who scored above the DBC-P clinical cut-off. ate (see Table II). There was no correlation between
However, over one-third (37%) of those whose children DBC-T scores and autism severity (SCQ; r=0.06; p=0.33).
scored above cut-off had not sought any help. Multiple linear regression showed higher DBC-T scores
were associated with greater family size/more children
Teacher reports of emotional and behaviour problems (F4,200=2.75, p=0.03, b= 5.38, p=0.002) but not with any
DBC-T data were available for 228 of the children with other family factors or school placement.
parent data (see Table I). Missing data were largely due to
teachers not returning the questionnaire. Children lacking Agreement between parent and teacher reports
teacher data were slightly older than those with teacher Two-thirds (64%) of children above clinical cut-off on the
data (mean 7y 1mo, SD 1y 1mo and mean 6y 8mo, SD 1.2 DBC-P were also above the cut-off on the DBC-T, indi-
respectively, t[275]=2.1, p=0.04), but they did not differ in cating that significantly more parents than teachers rated
terms of SCQ score (p=0.76) or sex (p=0.12). children as having emotional/behavioural problems (one-
Mean total score on the DBC-T was 38.1 (SD 21.1); sample proportion test, z[n=228]= 6.2, p<0.001).
62% scored above the cut-off for major emotional and/or There was no significant correlation between DBC-P
behavioural disturbance. Mean total and subscale scores for and DBC-T total scores (r=0.07, p=0.29). The discrepancy
this ASD sample were significantly higher than those for between caseness (reaching cut-off) on the DBC-P and the
the normative intellectual disability sample15 (p<0.05 in DBC-T was examined using multinomial regression for

Emotional and Behavioural Problems in ASD Susie Chandler et al. 205

Table III: Developmental Behaviour Checklist Primary Carer Version
problems were also reported compared with children of
scores at times 1 and 2 (n=93)
similar age; for example disrupted sleep in 59%, 70% fussy
eaters, and 24% and 34% respectively having soiling and
Mean score Mean score urinating problems (despite being toilet-trained).
(SD), time 1 (SD), time 2 r value
Two-thirds of children with ASD who were above the
Total behaviour 71.8 (27.5)b 59.4 (2.6)b 0.79c DBC-P cut-off were also above cut-off on the teacher
problem score
report, indicating pervasiveness of problems. Problems
Disruptive/Antisocial 21.8 (10.3)b 17.8 (9.6)b 0.79c
Self-absorbed 23.5 (12.2)b 19.2 (10.8)b 0.78c were persistent. Most children (81%) initially above cut-off
Communication 10.7 (4.7)b 9.1 (2.8)b 0.66c remained above cut-off after an average period of
Disturbance
14 months, although total problem scores reduced some-
Anxiety 8.1 (3.9)b 6.6 (3.4)b 0.75c
Social Relating 6.3 (3.0)a 5.6 (2.8)a 0.51c what over time, consistent with previous studies.27,28 Nev-
Autism Screening 28.0 (10.6)b 24.0 (10.5)b 0.78c ertheless, less than half the parents/carers of these children
Algorithm
had sought help for these difficulties.
Depression scale 6.0 (3.4)b 4.7 (2.9)b 0.78c
Hyperactivity scale 7.7 (3.1)b 6.8 (3.2)b 0.70c The lack of association between overall rate of parent-
Anxious Behaviour 6.0 (3.3)b 5.2 (3.1)b 0.77c reported emotional and behaviour problems and child
Rating Scale
factors (i.e. sex, IQ, language, age) is consistent with the
Paired Student’s t-test, p<0.05. bPaired Student’s t-test, p<0.001.
a
literature in ASD6,11 and different from both general popu-
Pairwise correlation, p<0.001.
c
lation samples and clinical groups with and without intel-
lectual disability.5,7 However, in contrast to Simonoff
each of the four possible concordance/discordance catego- et al.,11 severity of ASD in this study was associated with
ries (see Appendix S1 for details). Being above cut-off on parental report of problems (although not teacher report).
the DBC-P but not the DBC-T, relative to being above Possible explanations are differences in age of the partici-
cut-off on both, was associated with living in a home with pants and the measures used.
more children (Wald[1]=17.4, p<0.001), higher IQ (Wald Consistent with studies of the general population5 and
[1]=11.4, p<0.005), and female sex (Wald[1]=9.4, p<0.005). of intellectual disability7 and some studies of ASD,29
although not all,11 psychosocial factors (higher deprivation,
Persistence of emotional and behavioural problems over parental unemployment, and number of children in the
time home, but not parental education or ethnicity) were associ-
Ninety-three families repeated the DBC-P after an average ated with higher parental ratings of emotional and behav-
interval of 14 months (SD 4.6; range 2–23). They did not iour problems. Also consistent with other studies, type of
differ from the other 184 in terms of age or deprivation symptoms varied with IQ. Children with IQ<70 were more
index (Student’s t-tests, p=0.12 and 0.17 respectively) but self-absorbed than others,6 and children with IQ>70 scored
they had a slightly lower mean IQ (67.6 vs 75.3, p=0.02) more highly for depression, anxiety,30 and attention-defi-
and differed, by design, in the percentage of males (57% vs cit–hyperactivity disorder.30 Higher DBC-T scores were
77%, v2=58.9, p<0.001) because females were deliberately associated with greater family size but no other family fac-
oversampled to obtain sufficient numbers for analysis of tors. Discrepancy between parental and teacher reports of
sex. There was a reduction in total and subgroup scores overall problem severity (DBC-P>DBC-T) tended to be
from time 1 to time 2 (see Table III) but 81% of those related to female sex, higher IQ, and larger family size. It
above cut-off initially remained above cut-off at time 2. is possible that children with higher IQ respond positively
Scores at time 1 and time 2 were highly correlated (r[93] to the structure and expectations of school; alternatively,
=0.79 p<0.001). Three children below cut-off at time 1 they may contain or suppress any anxiety or distress they
scored above cut-off at time 2; 14 children were above cut- experience in school and thus behave differently at home
off at time 1 but not time 2. Multinomial regression analy- and in school. Different behaviour across home and school
sis on time 1/time 2 concordance (see Appendix S1) indi- situations is well recognized in child psychopathology and
cated that scoring above DBC-P cut-off at time 1 but not there is anecdotal evidence that females with ASD may be
time 2 relative to those scoring above cut-off at both time- more concerned to conform in school; therefore, parent
points was associated with lower SCQ total (Wald[1]=6.12, experience is of greater behaviour problems. Type of
p=0.013). No family variables (including whether or not school was not associated with either parent or teacher
parents reported seeking help for the problems at time 1) reports.
were related to change over time (i.e. DBC-P at time 1, The strengths of this study include a large, total-popula-
DBC-P at time 2). tion-derived cohort (although non-participants included
more males and had higher deprivation index, thus possibly
DISCUSSION underestimating total problems); young age of the children;
As in previous research,6,11 the present study identified standardized IQ scores available for almost all; data col-
high levels of emotional and behavioural problems in lected from both parents and teachers; and follow-up mea-
young children with ASD. Three-quarters scored above sures obtained for a subgroup of children. Limitations
clinical cut-off on the DBC-P. High rates of functional include no confirmation of clinical diagnoses using a

206 Developmental Medicine & Child Neurology 2016, 58: 202–208

research diagnostic assessment (although the SCQ was
used); the small number of females available to assess pos-
sible sex differences; lack of an adaptive behaviour mea-
sure; and reliance on checklist data rather than clinician
validation of symptoms. Furthermore, the DBC was devel-
oped for use with children with intellectual disability. Our
sample included children across the full IQ range, indeed
65% had an IQ<70. Although it is possible that the DBC
may not have been sensitive enough to detect all problems
in children with higher IQs, we found no relationship
between IQ and overall problem levels, and the variation
in patterns of problems according to IQ was consistent
with other studies.
Autism is currently being diagnosed at ever-younger
ages.31 Our findings, alongside those of others, show that
significant comorbid emotional and behaviour problems
can be detected as early as age 4 to 5 years. These difficul-
ties occur both at home and at school and persist over
time. The identification of comorbid problems is impor-
tant for parents and crucial in the management of ASD as
the impact of these additional problems can be reduced
using a range of evidence-based interventions.13 Consistent
with UK National Institute for Health and Care Excel-
lence guidance,13 systematic eliciting of co-occurring prob-
lems by clinicians as part of routine assessment and care in
ASD is recommended. Although several behaviour mea-
sures exist, parents of children across the IQ range found
the DBC easy to use and understand, and it covers a range
of behaviours including sleeping, eating, and toileting
problems. The availability of both Primary Carer and
Teacher Versions increases its value for measuring prob-
lems in different settings.
A CK N O W L E D G E M E N T S
We thank Lewisham Autism Support and the Complex Commu-
nication Diagnostic Service in Bromley for their support. We
thank all the families and schools who participated. This paper
represents independent research part funded by the National
Institute for Health Research (NIHR) Biomedical Research Cen-
tre at South London and Maudsley NHS Foundation Trust and
King’s College London and Research Autism. The views
expressed are those of the authors and not necessarily those of the
National Health Service, the National Institute for Health
Research, or the Department of Health. Funding source: Cloth-
workers’ Foundation, brokered by Research Autism. Grant num-
ber: R011217 Autism M10 2011/12. The authors have stated that
they had no interests that might be perceived as posing a conflict
or bias.
SUPPORTING INFORMATION
The following additional material may be found online:
Figure S1: The target population and response rate.
Appendix S1: Data analysis.
Appendix S2: Focus group procedure and questionnaire
selection.
Appendix S3: Sample characteristics and differences between
participating and non-participating families.
Appendix S4: Calculation of developmental quotient for chil-
dren for whom no standard IQ data were available.

REFERENCES
1. American Psychiatric Association. Diagnostic and Statis-
tical Manual of Mental Disorders. 5th edn. Washington,
DC: American Psychiatric Association, 2013.
2. Centers for Disease Control and Prevention. Prevalence
of autism spectrum disorder among children aged 8 years.
MMWR Morb Mortal Wkly Rep 2014; 63(SS02): 1–21.
3. Buescher AV, Cidav Z, Knapp M, Mandell DS. Costs of
autism spectrum disorders in the United Kingdom and
the United States. JAMA Pediatr 2014; 168: 721–8.
4. Matson JL, Cervantes PE. Commonly studied comorbid
psychopathologies among persons with autism spectrum
disorder. Res Dev Disabil 2014; 35: 952–62.
5. Green H, McGinty A, Meltzer H, Ford T, Goodman R.
Mental Health of Children and Young People in Great
Britain. Basingstoke: Palgrave Macmillan, 2005.
6. Brereton AV, Tonge JT, Einfeld S. Psychopathology in
children and adolescents with autism compared to young
people with intellectual disability. J Autism Dev Disord
2006; 36: 863–70.
7. Emerson E, Hatton C. Mental health of children and
adolescents with intellectual disabilities in Britain. Br J
Psychiatry 2007; 191: 493–99.
8. Totsika V, Hasting R, Emerson E, Lancaster G, Ber-
ridge D. A population-based investigation of behavioural
and emotional problems and maternal mental health:
associations with autism spectrum disorder and intellec-
tual disability. J Child Psychol Psychiatry 2011; 52: 91–9.
9. Herring S, Gray K, Taffe J, Tonge B, Sweeney D, Ein-
feld S. Behavioural and emotional problems in toddlers
with pervasive developmental disorders and developmen-
tal delay and association with parental mental health. J
Intellect Disabil Res 2006; 50: 874–82.
10. Maskey M, Warnell F, Parr JR, LeCouteur A, McCona-
chie H. Emotional and behavioural problems in children
with autism spectrum disorder. J Autism Dev Disord
2013; 43: 851–9.
11. Simonoff E, Pickles A, Charman T, Chandler S, Loucas
T, Baird G. Psychiatric disorders in children with autism
spectrum disorders: prevalence, comorbidity, and associ-
ated factors in a population-derived sample. J Am Acad
Child Adolesc Psychiatry 2008; 47: 921–9.
12. Buck TR, Viskochil J, Farley M, et al. Psychiatric com-
orbidity and medication use in adults with autism spec-
trum disorder. J Autism Dev Disord 2014; 44: 3063–71.
13. National Institute for Health and Care Excellence. Aut-
ism Diagnosis in Children and Young People: Recogni-
tion, Referral and Diagnosis of Children and Young
People on the Autism Spectrum. CG 128 and the
Management and Support of Children and Young Peo-
ple on the Autism Spectrum CG 170. London:
National Institute for Health and Care Excellence,
2011 and 2013.
14. Rutter M, LeCouteur A, Lord C. The Autism Diagnos-
tic Interview-Revised (ADI-R). Los Angeles, CA: Wes-
tern Psychological Services, 2003.
15. Skuse D, Warrington R, Bishop D, et al. The develop-
mental, dimensional and diagnostic interview (3di): a novel
computerized assessment for autism spectrum disorders. J
Am Acad Child Adolesc Psychiatry 2004; 43: 548–58.
16. Wing L, Leekam SR, Libby SJ, et al. The Diagnostic
Interview for Social and Communication Disorders
(DISCO): background, inter-rater reliability and clinical
use. J Child Psychol Psychiatry 2002; 43: 307–25.
17. Lord C, Risi S, Lambrecht L, et al. The Autism Diag-
nostic Observation Schedule-Generic (ADOS-G): a stan-
dard measure of social and communication deficits
associated with the spectrum of autism. J Autism Dev
Disord 2000; 30: 205–23.
18. Einfeld SL, Tonge BJ. Manual for the Developmental
Behaviour Checklist: Primary Carer Version (DBC-P)
and Teacher Version (DBC-T). 2nd edn. Melbourne,
Vic.: Monash University Centre for Developmental Psy-
chiatry and Psychology, 2002.
19. Einfeld SL, Tonge BJ. The Developmental Behaviour
Checklist: the development and validation of an instru-

Emotional and Behavioural Problems in ASD Susie Chandler et al. 207

 ment to access behavioural and emotional disturbance in
children and adolescents with mental retardation. J Aut-
ism Dev Disord 1995; 25: 81–104.
20. Einfeld SL, Tonge BJ. Population prevalence of psycho-
pathology in children and adolescents with intellectual
disability: II epidemiological findings. J Intellect Disabil
Res 1996; 40: 99–109.
21. Rutter M, Bailey A, Lord C. The Social Communication
Questionnaire. 1st edn. Los Angeles, CA: Western Psy-
chological Services, 2003.
22. Department for Communities and Local Government.
The English Indices of Deprivation 2007. Available from:
http://webarchive.nationalarchives.gov.uk/2010041018003
8/http://communities.gov.uk/communities/neighbourhoo
drenewal/deprivation/deprivation07/ (accessed 11 April 2011).
208 Developmental Medicine & Child Neurology 2016, 58: 202–208
23. Wechsler D. Wechsler Intelligence Scale for Children
(IV-UK edition). London: The Psychological Corpora-
tion, 2003.
24. Wechsler D. Wechsler Pre-school and Primary Scale of
Intelligence (III-UK edition). San Antonio, TX: Har-
court Assessment, 2002.
25. Mullen EM. Mullen Scales of Early Learning (AGS edi-
tion). Circle Pines, MN: American Guidance Service, 1995.
26. Dunn LM, Dunn LM, Whetton C, Burley J. British Pic-
ture Vocabulary Scale. 2nd edn. London: NFER-Nel-
son, 1997.
27. Simonoff E, Jones CR, Baird G, Pickles A, Happe F,
Charman T. The persistence and stability of psychiatric
problems in adolescents with autism spectrum disorders.
J Child Psychol Psychiatry 2013; 54: 186–94.
28. Gray K, Keating C, Taffe J, Brereton A. Trajectory of
behavior and emotional problems in autism. Am J Intel-
lect Dev Disabil 2012; 117: 121–33.
29. Midouhas E, Yogaratnam A, Flouri E, Charman T. Tra-
jectories of psychopathology in young children with aut-
ism spectrum disorder: the role of family poverty and
parenting. J Am Acad Child Adolesc Psychiatry 2013; 52:
1057–65.
30. Mazzone L, Ruta L, Reale L. Psychiatric comorbidities
in Asperger syndrome and high functioning autism:
diagnostic challenges. Ann Gen Psychiatry 2012; 11: 16.
31. Daniels AM, Mandell DS. Explaining differences in age
at autism spectrum disorder diagnosis: a critical review.
Autism 2014; 18: 583–97.