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: [email protected]

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 difficulty does vary with IQ, age, and sex.6 Psychiatric
disorder characterized by impairments in reciprocal social disorders also have a high prevalence in adults12 and,
interaction, communication, and repetitive, stereotyped together with functional problems, can have as great an
interests and behaviours.1 Recent estimates suggest a prev- adverse impact as core ASD symptoms. There is, neverthe-
alence rate of over 1%.2 ASD is associated with high co- less, a range of evidence-based interventions that could
morbidity and significant costs to individuals, families, reduce the effects of these problems.13 Hence systematic
and services.3 Emotional and behavioural problems in assessment of emotional/behavioural difficulties by clini-
ASD are frequent,4 and rates of social anxiety, attention- cians is crucial. This paper describes the use of parent and
deficit–hyperactivity disorder and oppositional disorder are teacher questionnaires to assess comorbid emotional and
elevated compared both with the general population5 and behavioural problems in a community sample of young
with children with intellectual disability.6–8 Functional children (age 4–9y) with ASD.
problems in sleeping, eating, and toileting are also
increased. High rates of behavioural and emotional distur- METHOD
bance are evident from pre-school onwards9 and many The study was approved by Guy’s Hospital Research Eth-
children have two or more comorbid problems.10,11 In ics Committee (08/H0804/37) and Bromley and Lewisham
non-ASD populations with and without intellectual disabil- Local Research Ethics Committees (RDLEWBR 428).
ity, prevalence and types of emotional and behavioural dif-
ficulties are associated with age, sex, IQ, ethnic group, and Recruitment procedures
social disadvantage.5,7 In ASD these factors are less clearly The target population comprised all children born between
linked to psychiatric co-morbidity6,11 although the type of 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 What this paper adds
local multidisciplinary teams and living in two London • Three-quarters of 4- to 8-year-olds with autism have parent-reported emo-
boroughs with a broad range of socio-economic circum- tional and behavioural problems.
stances and ethnic backgrounds. In both boroughs, • Two-thirds of these also have teacher-reported problems.
children suspected of having ASD receive a neurodevelop- • Problems persist over time in 80%, and identification is possible at 4 to
5 years.
mental assessment from the community paediatrician. A • The Developmental Behaviour Checklist assesses a wide range of difficulties
few are diagnosed at this appointment but most are in children with autism spectrum disorder (ASD).
referred onto the multidisciplinary communication clinic. • Systematic use of such a questionnaire is recommended in routine clinical
After a speech and language assessment and report from care of children with ASD.
nursery/school, children then attend the multidisciplinary
specific psychiatric syndromes (Autism Screening Algo-
clinic consisting of a paediatrician, a speech and language
rithm; Depression scale; Hyperactivity scale, and Anxious
therapist, or psychologist for a formal assessment of
Behaviour Rating Scale). The total behaviour problem
features specific to ASD. Measures include the Autism
score (range 0–192) indicates overall level of disturbance; a
Diagnostic Interview-Revised,14 Developmental, Diagnos-
cut-off score of at least 46 is recommended for identifying
tic and Dimensional Interview,15 Diagnostic Interview for
clinically significant emotional and/or behavioural prob-
Social Communication Disorder,16 or local pro forma and
lems. The DBC Teacher Version (DBC-T) has 94 items; a
the Autism Diagnostic Observation Schedule.17
total score of at least 30 is recommended as the cut-off for
Eligible families (n=447) were mailed invitations to par-
identifying caseness.
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, Autism symptomatology
researchers telephoned again and offered to re-mail the Autism symptomatology was measured using the parent-
questionnaires or complete them with parents over the rated Social Communication Questionnaire Lifetime
telephone or at home. To assess pervasiveness of problems, version (SCQ).21 It comprises 39 items scored 0 or 1; a
teachers were asked to complete the teacher version of the cut-off of more than 15 is recommended for identifying
questionnaire. To assess the persistence of difficulties a potential cases of ASD.
subset of parents completed the questionnaire on two occa-
sions (times 1 and 2). For the assessment at time 2, females Demographic characteristics
were over-sampled to provide adequate numbers for analy- Demographic characteristics were collected by means of a
sis (further details in Appendix S1, online supporting infor- parent questionnaire. Postcode data were used to access a
mation). deprivation index (The English Indices of Deprivation
2007),22 which ranks small geographical areas across Eng-
Measures land according to deprivation level, based on income, edu-
Emotional and behaviour problems cation, employment, and living environment (a higher
A focus group of eight parents with children with ASD index score means greater deprivation).
aged younger than 10 years was recruited to determine
which of several questionnaires, commonly used in clinical Child assessments
practice in the UK, best described their child’s emotional IQ was measured by the research team, trained and experi-
and/or behavioural problems and was most acceptable to enced in psychometric assessments, using either the
them (details in Appendix S2, online supporting informa- Wechsler Intelligence Scale for Children,23 Wechsler Pre-
tion). The Developmental Behaviour Checklist (DBC18) school and Primary Scale of Intelligence,24 or Mullen
was selected as the preferred instrument for the study. Par- Scales of Early Learning25 depending on chronological age
ents rated it positively in terms of acceptability, ease of and developmental level (Appendix S2). Parents were also
use, clarity of questions, scoring, and range of questions, asked, ‘At what age do you think your child is functioning
and there are parallel parent and teacher versions that overall?’. The British Picture Vocabulary Scale26 was used
allow assessment of problems across settings. to measure receptive language for children who had suffi-
The DBC Primary Carer Version (DBC-P) is a 96-item cient language to access the test.
behaviour checklist covering a broad range of behaviours,
each rated as 0 (‘not true as far as I know’), 1 (‘somewhat Data analysis
or sometimes true’), or 2 (‘very or often true’). It has satis- Statistical analyses used STATA 11 (StatCorp, College Sta-
factory internal consistency, interrater and test–retest reli- tion, TX, USA, 2009). For some analyses IQ was treated
ability, and concurrent validity with other psychopathology as continuous and for others as a dichotomous variable
measures, particularly in samples of children and adoles- (<70/>70). For sleeping, eating, and toileting problems, the
cents with intellectual disability.19,20 The DBC has five ‘somewhat’/’sometimes’ and ‘very often’/’often’ categories
empirically derived subscales (Disruptive/Antisocial; Self- of the DBC were combined to create a dichotomous score.
absorbed; Communication Disturbance; Anxiety; Social- Associations between DBC-P/T scores and background
relating), and four scales that can be used to identify 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 child with a low score on the SCQ score (i.e. total <10;
linear regression. Multinomial logistic regression was used n=28) were checked with local clinicians; diagnosis was
to explore factors associated with discrepancies (i.e. above/ confirmed in all cases and none was excluded from the
below clinical cut-off) between primary carer (hereafter sample.
referred to as parent) and teacher questionnaires, and to Cognitive assessments were completed for 258 children.
explore factors associated with changes in parent question- Full-scale IQ scores were calculated for 211 (67 on the
naires (i.e. above/below clinical cut off) at times 1 and 2 Wechsler Intelligence Scale for Children;23 144 on the
(see Appendix S1 for full details). Wechsler Preschool and Primary Scale of Intelligence24).
For children tested on the Mullen Scales of Early Learn-
RESULTS ing,25 the composite standard score was used when possible
Participant characteristics (n=13); for those above the Mullen Scales of Early Learn-
Responses were received from 362 of 447 (81%) families ing age range (n=34), age-equivalents were used to derive a
(see Figure S1, online supporting information). Parental ratio IQ. Those with a Mullen Scales of Early Learning
questionnaires were completed on 277 children (62%), half ratio IQ<20 (n=11) were assigned an IQ of 19 to reflect
by post, the remainder by telephone or home visit. Non- their very low ability. Parental estimates of functional age
participating families had a higher mean deprivation index were also used to generate a parent-estimated developmen-
(t[443])=3.39, p<0.001) and contained a higher proportion tal quotient for 15 children (details in Appendix S4, online
of males (v2[1, n=447]=5.36, p=0.021) (see Appendix S3, supporting information). The mean IQ estimate for the
online supporting information, for details of participants sample was 72.7; 35% had an IQ<70; 21.6% had an
and non-participants at initial assessment). Mean age of IQ<50. Missing cognitive data were because of lack of
child participants at recruitment was 6 years (SD 1y 1mo) parental consent or child compliance issues.
and at first assessment 6 years 10 months (SD 1y 2mo). DBC-P scores are presented in Table I. The internal
Most (77%, n=214) attended mainstream school; 44 consistency of each of the subscales (Disruptive/Antisocial,
attended special schools; 15 attended special units within Self-absorbed, Communication Disturbance, Anxiety,
mainstream schools; three were home-schooled; one Social Relating), the Autism Screening Algorithm, Depres-
attended mainstream nursery. The clinical records of any 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 Teacher Versions increases its value for measuring prob-
used); the small number of females available to assess pos- lems in different settings.
sible sex differences; lack of an adaptive behaviour mea-
sure; and reliance on checklist data rather than clinician A CK N O W L E D G E M E N T S
validation of symptoms. Furthermore, the DBC was devel- We thank Lewisham Autism Support and the Complex Commu-
oped for use with children with intellectual disability. Our nication Diagnostic Service in Bromley for their support. We
sample included children across the full IQ range, indeed thank all the families and schools who participated. This paper
65% had an IQ<70. Although it is possible that the DBC represents independent research part funded by the National
may not have been sensitive enough to detect all problems Institute for Health Research (NIHR) Biomedical Research Cen-
in children with higher IQs, we found no relationship tre at South London and Maudsley NHS Foundation Trust and
between IQ and overall problem levels, and the variation King’s College London and Research Autism. The views
in patterns of problems according to IQ was consistent expressed are those of the authors and not necessarily those of the
with other studies. National Health Service, the National Institute for Health
Autism is currently being diagnosed at ever-younger Research, or the Department of Health. Funding source: Cloth-
ages.31 Our findings, alongside those of others, show that workers’ Foundation, brokered by Research Autism. Grant num-
significant comorbid emotional and behaviour problems ber: R011217 Autism M10 2011/12. The authors have stated that
can be detected as early as age 4 to 5 years. These difficul- they had no interests that might be perceived as posing a conflict
ties occur both at home and at school and persist over or bias.
time. The identification of comorbid problems is impor-
tant for parents and crucial in the management of ASD as SUPPORTING INFORMATION
the impact of these additional problems can be reduced The following additional material may be found online:
using a range of evidence-based interventions.13 Consistent Figure S1: The target population and response rate.
with UK National Institute for Health and Care Excel- Appendix S1: Data analysis.
lence guidance,13 systematic eliciting of co-occurring prob- Appendix S2: Focus group procedure and questionnaire
lems by clinicians as part of routine assessment and care in selection.
ASD is recommended. Although several behaviour mea- Appendix S3: Sample characteristics and differences between
sures exist, parents of children across the IQ range found participating and non-participating families.
the DBC easy to use and understand, and it covers a range Appendix S4: Calculation of developmental quotient for chil-
of behaviours including sleeping, eating, and toileting dren for whom no standard IQ data were available.
problems. The availability of both Primary Carer and

REFERENCES
1. American Psychiatric Association. Diagnostic and Statis- associations with autism spectrum disorder and intellec- National Institute for Health and Care Excellence,
tical Manual of Mental Disorders. 5th edn. Washington, tual disability. J Child Psychol Psychiatry 2011; 52: 91–9. 2011 and 2013.
DC: American Psychiatric Association, 2013. 9. Herring S, Gray K, Taffe J, Tonge B, Sweeney D, Ein- 14. Rutter M, LeCouteur A, Lord C. The Autism Diagnos-
2. Centers for Disease Control and Prevention. Prevalence feld S. Behavioural and emotional problems in toddlers tic Interview-Revised (ADI-R). Los Angeles, CA: Wes-
of autism spectrum disorder among children aged 8 years. with pervasive developmental disorders and developmen- tern Psychological Services, 2003.
MMWR Morb Mortal Wkly Rep 2014; 63(SS02): 1–21. tal delay and association with parental mental health. J 15. Skuse D, Warrington R, Bishop D, et al. The develop-
3. Buescher AV, Cidav Z, Knapp M, Mandell DS. Costs of Intellect Disabil Res 2006; 50: 874–82. mental, dimensional and diagnostic interview (3di): a novel
autism spectrum disorders in the United Kingdom and 10. Maskey M, Warnell F, Parr JR, LeCouteur A, McCona- computerized assessment for autism spectrum disorders. J
the United States. JAMA Pediatr 2014; 168: 721–8. chie H. Emotional and behavioural problems in children Am Acad Child Adolesc Psychiatry 2004; 43: 548–58.
4. Matson JL, Cervantes PE. Commonly studied comorbid with autism spectrum disorder. J Autism Dev Disord 16. Wing L, Leekam SR, Libby SJ, et al. The Diagnostic
psychopathologies among persons with autism spectrum 2013; 43: 851–9. Interview for Social and Communication Disorders
disorder. Res Dev Disabil 2014; 35: 952–62. 11. Simonoff E, Pickles A, Charman T, Chandler S, Loucas (DISCO): background, inter-rater reliability and clinical
5. Green H, McGinty A, Meltzer H, Ford T, Goodman R. T, Baird G. Psychiatric disorders in children with autism use. J Child Psychol Psychiatry 2002; 43: 307–25.
Mental Health of Children and Young People in Great spectrum disorders: prevalence, comorbidity, and associ- 17. Lord C, Risi S, Lambrecht L, et al. The Autism Diag-
Britain. Basingstoke: Palgrave Macmillan, 2005. ated factors in a population-derived sample. J Am Acad nostic Observation Schedule-Generic (ADOS-G): a stan-
6. Brereton AV, Tonge JT, Einfeld S. Psychopathology in Child Adolesc Psychiatry 2008; 47: 921–9. dard measure of social and communication deficits
children and adolescents with autism compared to young 12. Buck TR, Viskochil J, Farley M, et al. Psychiatric com- associated with the spectrum of autism. J Autism Dev
people with intellectual disability. J Autism Dev Disord orbidity and medication use in adults with autism spec- Disord 2000; 30: 205–23.
2006; 36: 863–70. trum disorder. J Autism Dev Disord 2014; 44: 3063–71. 18. Einfeld SL, Tonge BJ. Manual for the Developmental
7. Emerson E, Hatton C. Mental health of children and 13. National Institute for Health and Care Excellence. Aut- Behaviour Checklist: Primary Carer Version (DBC-P)
adolescents with intellectual disabilities in Britain. Br J ism Diagnosis in Children and Young People: Recogni- and Teacher Version (DBC-T). 2nd edn. Melbourne,
Psychiatry 2007; 191: 493–99. tion, Referral and Diagnosis of Children and Young Vic.: Monash University Centre for Developmental Psy-
8. Totsika V, Hasting R, Emerson E, Lancaster G, Ber- People on the Autism Spectrum. CG 128 and the chiatry and Psychology, 2002.
ridge D. A population-based investigation of behavioural Management and Support of Children and Young Peo- 19. Einfeld SL, Tonge BJ. The Developmental Behaviour
and emotional problems and maternal mental health: ple on the Autism Spectrum CG 170. London: 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 23. Wechsler D. Wechsler Intelligence Scale for Children 28. Gray K, Keating C, Taffe J, Brereton A. Trajectory of
children and adolescents with mental retardation. J Aut- (IV-UK edition). London: The Psychological Corpora- behavior and emotional problems in autism. Am J Intel-
ism Dev Disord 1995; 25: 81–104. tion, 2003. lect Dev Disabil 2012; 117: 121–33.
20. Einfeld SL, Tonge BJ. Population prevalence of psycho- 24. Wechsler D. Wechsler Pre-school and Primary Scale of 29. Midouhas E, Yogaratnam A, Flouri E, Charman T. Tra-
pathology in children and adolescents with intellectual Intelligence (III-UK edition). San Antonio, TX: Har- jectories of psychopathology in young children with aut-
disability: II epidemiological findings. J Intellect Disabil court Assessment, 2002. ism spectrum disorder: the role of family poverty and
Res 1996; 40: 99–109. 25. Mullen EM. Mullen Scales of Early Learning (AGS edi- parenting. J Am Acad Child Adolesc Psychiatry 2013; 52:
21. Rutter M, Bailey A, Lord C. The Social Communication tion). Circle Pines, MN: American Guidance Service, 1995. 1057–65.
Questionnaire. 1st edn. Los Angeles, CA: Western Psy- 26. Dunn LM, Dunn LM, Whetton C, Burley J. British Pic- 30. Mazzone L, Ruta L, Reale L. Psychiatric comorbidities
chological Services, 2003. ture Vocabulary Scale. 2nd edn. London: NFER-Nel- in Asperger syndrome and high functioning autism:
22. Department for Communities and Local Government. son, 1997. diagnostic challenges. Ann Gen Psychiatry 2012; 11: 16.
The English Indices of Deprivation 2007. Available from: 27. Simonoff E, Jones CR, Baird G, Pickles A, Happe F, 31. Daniels AM, Mandell DS. Explaining differences in age
http://webarchive.nationalarchives.gov.uk/2010041018003 Charman T. The persistence and stability of psychiatric at autism spectrum disorder diagnosis: a critical review.
8/http://communities.gov.uk/communities/neighbourhoo problems in adolescents with autism spectrum disorders. Autism 2014; 18: 583–97.
drenewal/deprivation/deprivation07/ (accessed 11 April 2011). J Child Psychol Psychiatry 2013; 54: 186–94.

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