Article

Persistence and Change in Pediatric Symptom Checklist Scores Over 10 to 18 Months

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

There are many studies of the Pediatric Symptom Checklist (PSC), but none has followed a naturalistic sample longitudinally. We aimed to examine persistence and change in PSC scores over time in children seen in an ambulatory pediatric setting. The sample of 1033 patients was PSC screened at 2 consecutive preventive care visits (10 to 18 months apart) in 2 pediatric clinics. Longitudinal analyses were conducted to assess predictors of change in PSC category and score. Approximately 30% of the initially screened population did not return for preventive pediatric care. Those who did not return were significantly more likely to have positive PSC scores than those who returned (8% compared with 4.3%, P < .01). PSC scores were highly stable at visit 2 for those who initially scored negative, but they fluctuated more for those who initially scored positive. After controlling for sociodemographic variables and counseling at either visit, referral at visit 1 (P < .0001) predicted changes in mean PSC scores at visit 2. On average, PSC score decreased 3.2 points among those referred at visit 1 but increased 1.6 points in nonreferred children. This is the first study to document the stability and change in PSC scores in a sample of ambulatory pediatric patients. The statistically significant association between pediatrician referral and improved PSC scores provides evidence for the value of referral in primary care, although the study did not examine the relationship between PSC screening and referral. The high rate of positive scores in children who did not return for follow-up suggests the need for alternative strategies for this population.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... As previously described in the literature review, although pediatricians are seemingly aware of the need to screen children for behavioral and developmental disorders, several studies note that these screenings are not usually routine and providers seldom use standardized screening instruments ( Given that this project captured data on the prevalence of behavioral and developmental screening (including screening findings and subsequent referrals) prior to the MassHealth requirement of PCPs to use a standardized behavioral health screening tool, one might expect that with the implementation of universal and formal screening of a child's behavioral and developmental health, identification of needs will increase and concomitantly the number of referrals to specialty care, early intervention, and improved health outcomes. Based on the findings of this CTR project, our results are quite consistent with the literature showing numerous examples of screening using validated instruments in the context of specific practice improvement initiatives (Gall, Pagano, Desmond, Perrin, & Murphy, 2000;Garg et al., 2007;Hacker, Williams, Myagmarjav, Cabral, & Murphy, 2009;Murphy et al., 1996;Schonwald, Huntington, Chan, Risko, & Bridgemohan, 2009). Schonwald and colleagues (2009) noted success in their screening initiative following careful attention to workflow and the involvement and training of office staff. ...
... • Hacker, 2006: 6.0% of 1668 children 5-19 years of age screened with the PSC at a large outpatient practice within a public hospital system were found to have positive scores. • Hacker, 2009: between 4.3% and 8.0% of over 1000 children screened with the PSC in two hospital-based outpatient pediatric clinics scored above the cut-off for a positive PSC score, depending on whether they returned for a second visit after their initial screening or not, respectively. ...
... Families covered by MassHealth may be moving between providers and practices as a result of poverty and other social vulnerabilities. The literature has long suggested that these children are more apt to have behavioral and mental health needs (among a number of adverse health outcomes) and should be regularly screened in the primary care setting (Gall et al., 2000;Garg et al., 2007;Hacker et al., 2009;Jee, Tonniges, & Szilagyi, 2008;Murphy et al., 1996;Weinreb, Nicholson, Williams, & Anthes, 2007). Given these findings from other researchers, coupled with the potential for missing some 'screens' and/or referrals by only abstracting only well child visits, it may be that our results truly underestimate the extent to which children are being screened for behavioral health conditions, documented to have positive screens referred for services, and treated for these conditions. ...
Article
The first Clinical Topic Review was conducted in order to better understand how behavioral health screenings were occurring for children and adolescents during well visits prior to the implementation of a requirement that primary care providers perform behavioral health screening using a standardized behavioral health screening tool during every well child visit.
... In two studies (Jellinek et al. 1988;Murphy, Reede, Jellinek & Bishop, 1992) in which the results from the PSC were compared to results from the CBCL, the PSC exhibited high rates of overall agreement (79% and 92%), sensitivity (the percentage of all true cases are identified accurately 95% and 88%) and specificity (the percentage of all true non cases identified correctly 68% and 100%). In the first longitudinal examination of the stability and change in PCS scores in a sample of ambulatory patients (Hacker, Williams, Myagmarjav, Cabral & Murphy, 2009), the referral process was identified as playing an important role in children's mental health. A pediatrician's referral for additional mental health services for children with positive PSC scores resulted in PSC score improvement among children that obtained follow-up mental health services. ...
... Nursing researchers, educators and clinicians have called for increased attention to the effectiveness of preventive strategies (Breitenstein et al., 2007;Campo et al., 2005;Carter et al., 2006;Courey, 2006;Evans, 2009;Grossman et al., 2007;Puskar & Grabiak, 2008;Staten, 2008;Yearwood & McClowry, 2008). In support of previous research implications made by Hacker et al. (2009) urging research which examines the mental health services provided by pediatricians, implications from this study urge further research examining the specific mental health services provided by SN. Research to identify measures that will increase SN involvement, integration of services with primary care providers and role expansion is also imperative. ...
Article
Full-text available
The purpose of this qualitative study was to explore school nurses’ (SN) perceptions of factors influencing their ability to identify, refer, and provide mental health services to students with early signs of mental, emotional, and behavioral (MEB) needs. The National Research Council and Institute of Medicine have urged a preventive public health approach to decrease adverse outcomes of unidentified and untreated MEB needs among children (O’Connell, 2009). Historically and theoretically based in public health, SN have daily contact with students and are in an optimal location for early identification, referral and provision of services, yet little empirical research describing their role is available. Five focus groups with 29 SN were conducted and four themes emerged through analysis of data: Frequent flyers : student visits to SN offices, the observations that alert SN to potential MEB needs; Digging to get the whole picture : the process SN frequently used to collect information necessary to confirm MEB needs; Road to referral : the resources used and barriers encountered within the referral process; and, Safety zone : the important role SN play in the provision of services to students with early signs of MEB needs. Within the provision of services was a collective subtheme across all five focus groups: What we need to better help our kids. In this category SN identified their educational limitations and learning needs, as well as potential strategies to improve provision of services for students with MEB needs. The findings of this study provide a lens into the complex and little explored are of early identification, referral and intervention processes used by SN to care for students with MEB needs. Understanding the role of the SN is a critical first step towards improving outcomes.
... Often children are given psychopharmacologic treatment, inadequate counseling and referrals to mental health specialists that are not completed. Interestingly, a recent study by Hacker et al. [75]. found that a pediatrician's mental health referral was associated with a significant improvement on follow-up scores of the Pediatric Symptom Checklist [76].even when more than threequarters of the patients did not utilize the mental health services, which may have been due to pediatrician counseling between primary care visits. ...
Article
Suicide is critical public health problem that primary care physicians potentially can help address given that concerned patients frequently visit them in the weeks and months preceding the successful suicide. This article contemplates issues placing the patient at high risk for successful suicide and clinical valuation techniques available to the primary care physician. Patients identified as being at risk of attractive suicidal or those who have a equal of suicidal ideation or behavior judged apposite for management in the primary care setting should be monitored for risk at regular intervals. It is extremely significant to learn about and try to contextualize the patients' emotions that triggered the present crisis. Nurses can make sure that they have a thorough understanding of the present acuity, and all of the precipitating factors, and can exactly and collaboratively communicate with the caregivers and other involved medical teams.
... Often children are given psychopharmacologic treatment, inadequate counseling and referrals to mental health specialists that are not completed. Interestingly, a recent study by Hacker et al. [52] found that a pediatrician's mental health referral was associated with a significant improvement on follow-up scores of the Pediatric Symptom Checklist [53], even when more than three-quarters of the patients did not utilize the mental health services, which may have been due to pediatrician counseling between primary care visits. Continued collaborative efforts between primary and mental health teams are needed to provide comprehensive follow-up to positive screens. ...
Article
Every year, suicide claims the lives of tens of thousands of young people worldwide. Despite its high prevalence and known risk factors, suicidality is often undetected. Early identification of suicide risk may be an important method of mitigating this public health crisis. Screening youth for suicide may be a critical step in suicide prevention. This paper reviews suicide screening in three different settings: schools, primary care clinics and emergency departments (EDs). Unrecognized and thus untreated suicidality leads to substantial morbidity and mortality. With the onus of detection falling on nonmental health professionals, brief screening tools can be used to initiate more in-depth evaluations. Nonetheless, there are serious complexities and implications of screening all children and adolescents for suicide. Recent studies show that managing positive screens is a monumental challenge, including the problem of false positives and the burden subsequently posed on systems of care. Furthermore, nearly 60% of youth in need of mental health services do not receive the care they need, even after suicide attempt. Schools, primary care clinics and EDs are logical settings where screening that leads to intervention can be initiated. Valid, brief and easy-to-administer screening tools can be utilized to detect risk of suicide in children and adolescents. Targeted suicide screening in schools, and universal suicide screening in primary care clinics and EDs may be the most effective way to recognize and prevent self-harm. These settings must be equipped to manage youth who screen positive with effective and timely interventions. Most importantly, the impact of suicide screening in various settings needs to be further assessed.
... 10,[12][13][14] One recent study did evaluate the stability and change of PSC scores over an approximate one-year period in an outpatient primary care setting, with general stability noted over this time frame. 18 The PSC has been used in circumstances other than for routine periodic health maintenance assessments. Children presenting for illness or injury related medical visits (compared to preventive care medical contacts) have been shown to have higher rates of Positive screens on a brief version of the PSC (the PSC-17 screen contains a subset of items found in the full scale), 19 and the PSC has been useful in helping identify children with behavioral concerns during hospitalization for acute medical conditions. ...
Article
To examine screening results obtained by serial annual behavioral assessment of children with prenatal drug exposure. The Maternal Lifestyle Study enrolled children with prenatal cocaine exposure (PCE) at birth for longitudinal assessments of developmental, behavioral, and health outcomes. At 8, 9, 10, 11, and 12 years of age, caregivers rated participants on the Pediatric Symptom Checklist (PSC). Serial PSC results were compared with an established broad-based behavioral measure at 9, 11, and 13 years. PSC results were analyzed for 1081 children who had at least 2 annual screens during the 5-year time span. Most subjects (87%) had 4 or more annual screens rated by the same caregiver (80%). PSC scores (and Positive screens) over time were compared at different time points for those with and without PCE. Covariates, including demographic factors and exposures to certain other substances, were controlled. Children with PCE had significantly higher scores overall, with more Positive screens for behavior problems than children without PCE. Children with PCE had more externalizing behavior problems. Children exposed to tobacco prenatally and postnatally also showed higher PSC scores. Over time, PSC scores differed slightly from the 8-year scores, without clear directional trend. Earlier PSC results predicted later behavioral outcomes. Findings of increased total PSC scores and Positive PSC screens for behavioral concerns in this group of children with prenatal substance exposure support the growing body of evidence that additional attention to identification of mental health problems may be warranted in this high-risk group.
... Although a screening tool should not replace or override clinical judgment in detecting more subtle social-emotional problems, office-based screening can help providers to identify those with clinically significant problems who would benefit from a full mental health evaluation. Mounting evidence shows a significant discrepancy between need for mental health services and receipt of care in the general population 39 and in the child welfare population in particular. 40 Systematic screening in the primary care setting, using tools such as the SDQ, can help bridge this gap, and also provides the opportunity identify strengths. ...
Article
Full-text available
To assess the effectiveness of social-emotional screening in the primary care setting for youths in foster care. The setting was a primary care practice for all youth in home-based foster care in 1 county. Subjects were youths, aged 11 to 17 years, and their foster parents; both completed a Strengths and Difficulties Questionnaire at well-child visits. The Strengths and Difficulties Questionnaire is a previously validated 25-item tool that has 5 domains: emotional symptoms; conduct problems; hyperactivity/inattention; peer problems; and prosocial behaviors and an overall total difficulties score. We first compared youth versus parent Strengths and Difficulties Questionnaire scores and then assessed the accuracy of these Strengths and Difficulties Questionnaire scores by comparing them in a subsample of youths (n = 50) with results of home-based structured clinical interviews using the Children's Interview for Psychiatric Syndromes. Of 138 subjects with both youth and parent reports, 78% had prosocial behaviors (strengths), and 70% had 1 or more social-emotional problems. Parents reported significantly more conduct problems (38% vs 16%; P < .0001) and total difficulties (30% vs 16%; P = .002) than did youth. The Strengths and Difficulties Questionnaire had better agreement with the Children's Interview for Psychiatric Syndromes (n = 50) for any Strengths and Difficulties Questionnaire-identified problem for combined youth and foster-parent reports (93%), compared with youth report alone (54%) or parent report alone (71%). Although most youths in foster care have social-emotional problems, most have strengths as well. Youth and foster-parent perspectives on these problems differ. Systematic social-emotional screening in primary care that includes both youth and parent reports can identify youths who may benefit from services.
... Behavioral health screens improve identification rates and referral numbers and may affect timeliness of care (28)(29)(30)(31). Behavioral health screening and related increases in referrals are also associated with improved behavioral health outcomes measured at subsequent preventive care visits (for example, lower Pediatric Symptom Checklist [PSC] scores) (32,33). Thus, the positive and negative impacts of health information technology on behavioral health screening merit further attention. ...
Article
Full-text available
The objective was to determine whether transitioning from paper to electronic health records affected behavioral health screening rates in a large Northeastern pediatric practice. The study setting was a pediatric practice with seven pediatricians, serving about 6,000 patients. The patient population was diverse (54% nonwhite, 40% publicly insured or self-paying, and 31% non-English speakers). An interrupted times series design was used to evaluate the impact of electronic record implementation on behavioral health screening rates. The main outcome measure was the rate of such screening 18 months before and 36 months after implementation. The rate of behavioral health screening increased from 70% to 91% during the baseline period. The training period-six months before electronic record implementation-was associated with a 28% decline in adjusted screening rates (from 83.3% to 55.5%). Only 50% of eligible youths were screened in the first month after implementation. The screening rate took more than three years to recover to baseline levels, climbing to 82% by April 2008. Practice changes resulting from electronic record adoption were highly disruptive of care, and disruptions took several years to resolve completely. When medical assistants rather than physicians were tasked with transferring data from paper screening forms to the electronic record, reporting compliance improved. Compliance with Healthcare Effectiveness Data and Information Set standards and Medicaid performance measures will likely be similarly affected as electronic records are implemented nationwide. Although implementing a fully automated medical record has some benefits, the unintended effects on care after implementation must be acknowledged.
... Guided by empirical research documenting the disproportionate salience of early adaptational failures in pathological pathways (Egeland et aL, 1993;Sroufe et aL, 1990), early identification and intervention responsibilities have entered the domains of primary care providers and early educators (see Hagan, Shaw, & Duncan, 2008;Lawrence, Gootman, & Sim, 2009, for reviews of formal recommenda, dons by the Institute of Medicine, the U.S. Preventive Services, and the American Academy of Pediatrics). Both broad,spectrum screening with instruments, such as the Pediatric Symptom Checklist (Hacker, Williams, Myagmarjav, Cabral, & Murphy, 2009;Jellinek et al., 1999), and disorder,specific assessments, such as suicide and depression screen' ing for adolescents (Williams, O'Connor, Eder, & Whitlock, 2009), are increasingly common components of pediatric care, and these tools accurately identify the presence of disorder much earlier than would be the case without systematic screening. ...
Chapter
P sychopathology is an outcome of development (Sroufe, 1997). Yet development received scant attention in clinical psychiatry and remained wanting for empirical documentation well into the 1970s. In this chapter, we take stock of how a developmental perspective has informed our understanding of psychopathology over the past three decades and identify key areas in which a developmental framework should inform future investigations and applications. Illustrating core developmental principles through the complementary lenses of clinical research, classification, and practice, we generate specific recommen~ dations and highlight caveats for concern as we work to implement a developmental framework in clinical science and practice. Acknowledgments: Preparation of this chapter was supported by a grant from the National Science Foundation (#0951775) awarded to the first author. The authors wish to acknowl* edge the enduring legacy of Byron Egeland and Alan Sroufe, whose mentorship has shaped our own developmental trajectories and resulting scholarship in countless ways.
... Pediatric Symptom Checklist-17 (PSC-17) is a one page behavioral assessment tool that can be completed in <5 min. It has been previously validated in numerous studies in both clinical and non-clinical settings [3,29] Pagano et al., 2000) and has been used cross-culturally [35,41]; and as a screening instrument [18,25]. It has not been applied to a community-wide sample of U.S. children in foster care, and is widely used in clinical practice due to ease of scoring and ability to evaluate by sub-domains (overall score of clinical significance, and sub-domains of attention, externalizing problems, and internalizing problems). ...
Article
This article presents a pilot project implementing a mindfulness-based stress reduction program among traumatized youth in foster and kinship care over 10 weeks. Forty-two youth participated in this randomized controlled trial that used a mixed-methods (quantitative, qualitative, and physiologic) evaluation. Youth self-report measuring mental health problems, mindfulness, and stress were lower than anticipated, and the relatively short time-frame to teach these skills to traumatized youth may not have been sufficient to capture significant changes in stress as measured by electrocardiograms. Main themes from qualitative data included expressed competence in managing ongoing stress, enhanced self-awareness, and new strategies to manage stress. We share our experiences and recommendations for future research and practice, including focusing efforts on younger youth, and using community-based participatory research principles to promote engagement and co-learning. CLINICALTRIALS.GOV: Protocol Registration System ID NCT01708291. Copyright © 2015 Elsevier Ltd. All rights reserved.
... CHA clinics phased in the use of a validated screening tool during well-child visits from 2004 to 2007. Using data from the CHA data warehouse (16,17), we conducted an interrupted time-series (ITS) analysis of utilization rates in the months pre-and postimplementation of the behavioral health screening and colocation program among a rolling cohort of primary care pediatric patients receiving care. The CHA Institutional Review Board approved the study in 2011. ...
Article
Full-text available
The study sought to determine the impact of a pediatric behavioral health screening and colocation model on utilization of behavioral health care. In 2003, Cambridge Health Alliance, a Massachusetts public health system, introduced behavioral health screening and colocation of social workers sequentially within its pediatric practices. An interrupted time-series study was conducted to determine the impact on behavioral health care utilization in the 30 months after model implementation compared with the 18 months prior. Specifically, the change in trends of ambulatory, emergency, and inpatient behavioral health utilization was examined. Utilization data for 11,223 children ages ≥4 years 9 months to <18 years 3 months seen from 2003 to 2008 contributed to the study. In the 30 months after implementation of pediatric behavioral health screening and colocation, there was a 20.4% cumulative increase in specialty behavioral health visit rates (trend of .013% per month, p=.049) and a 67.7% cumulative increase in behavioral health primary care visit rates (trend of .019% per month, p<.001) compared with the expected rates predicted by the 18-month preintervention trend. In addition, behavioral health emergency department visit rates increased 245% compared with the expected rate (trend .01% per month, p=.002). After the implementation of a behavioral health screening and colocation model, more children received behavioral health treatment. Contrary to expectations, behavioral health emergency department visits also increased. Further study is needed to determine whether this is an effect of how care was organized for children newly engaged in behavioral health care or a reflection of secular trends in behavioral health utilization or both.
... Pediatric Symptom Checklist-17 (PSC-17) is a one page behavioral assessment tool that can be completed in <5 min. It has been previously validated in numerous studies in both clinical and non-clinical settings [3,29] Pagano et al., 2000) and has been used cross-culturally [35,41]; and as a screening instrument [18,25]. It has not been applied to a community-wide sample of U.S. children in foster care, and is widely used in clinical practice due to ease of scoring and ability to evaluate by sub-domains (overall score of clinical significance, and sub-domains of attention, externalizing problems, and internalizing problems). ...
Conference Paper
Purpose Youth in foster care have a high prevalence of early trauma and social-emotional problems and may benefit from innovative group-based programs to promote peer socialization and stress management. Our study examines the feasibility of implementing an evidence-based mindfulness (Mindfulness-Based Stress Reduction, MBSR) program and impact on youth outcomes of social-emotional status, mindfulness, and attitudes. Methods A pilot randomized controlled trial of MBSR for youth in FC aged 14-21 yrs randomly assigned to the MBSR intervention (10 week group) or control (TAU: no program) groups. Youth in both arms completed identical pre/post quantitative measures. Our primary outcome was youth social-emotional well-being with the Pediatric Symptom Checklist-17(PSC-17); a secondary outcome assessed mindfulness with the Child Acceptance and Mindfulness Measures (CAMM). Intervention youth completed post-intervention focus groups. Results We recruited youth for the MBSR (n=24) and TAU (n=20) groups, with a target group size of 10 subjects for both arms. We had 100% attendance for all 10 sessions in the group 1 intervention group, and 2 were lost to follow-up from our control group. Between the MBSR (n=24) and TAU (n=20) groups, there were no significant demographic differences or baseline assessment scores for PSC-17 or CAMM. We are currently completing our second group, and data for attendance and post-group 2 data are pending at this time. Preliminary data examining group 1 pre/post scores show significant improvement for 2 out of 3 youth with significant scores on the PSC-17 for total, internalizing, and externalizing scores. One youth score remained unchanged, and the majority of youth (8 of 11) did not score within clinically significant range. On the CAMM, 5 showed improvement in mindfulness, 3 remained unchanged, and 3 showed a decrease in mindfulness scoring. Main themes from qualitative data (2 focus groups; data from in-depth interviews pending at this time) included expressed competence in managing ongoing stress, enhanced awareness of one’s internal self, and new strategies to manage stress. Conclusion Preliminary data from this pilot study suggest that a subset of high-risk youth are motivated to participate in a novel youth group-based intervention to manage stress; however, baseline data indicate that youth may be under-reporting social-emotional problems. This may be due to a selective bias of recruitment among motivated participants or social-desirability influence on self-report. Additional qualitative work with foster parents and caseworkers may provide important additional insight into the impact of this pilot program for traumatized youth in FC.
... The results of psychosocial dysfunction are not surprising considering its predictive value with respect to the appearance of mental health problems in childhood. For this reason, the international literature has identified it as an effective screening element (Hacker, Williams, Myagmarjav, Cabral, & Murphy, 2009;Navon, Nelson, Pagano, & Murphy, 2001;Vogels, Crone, Hoekstra, & Reijneveld, 2009). In this and other studies (Perry et al., 2007;Perry & Weinstein, 1998), psychosocial dysfunction emerges as an adverse condition with a powerful effect on children's ability to respond with effectiveness to the demands posed by the school context. ...
Article
Full-text available
The Pediatric Symptom Checklist (PSC) is a widely used, parent-completed measure of children’s emotional and behavioral functioning. Previous research has shown that the PSC and its subscales are responsive to patient progress over the course of psychiatric treatment. In this naturalistic study, parents and clinicians of 1736 patients aged 17 or younger completed standardized measures at intake and 3-month follow-up appointments. We assessed the 5-item PSC Attention Subscale (PSC–AS) as a longitudinal measure of attention-related symptoms in routine outpatient psychiatry treatment. Secondarily, we compared PSC–AS scores with clinician-reported diagnoses, psychomotor excitation symptoms, and overall functioning. Change scores on the PSC–AS were larger among patients with ADHD diagnoses than those with non-ADHD diagnoses. Comparisons between PSC–AS scores and clinician reports also showed acceptable levels of agreement. Given its effectiveness in tracking attention-related symptoms, the PSC may be particularly useful as a quality assurance or treatment outcome measure for clinicians treating ADHD.
Article
Universal mental health screening in pediatric primary care is recommended, but studies report slow uptake and low rates of patient follow-through after referral to specialized services. This review examined possible explanations related to the process of screening, focusing on how parents and youth are engaged, and how providers evaluate and use screening results. A narrative synthesis was developed after a systematic review of 3 databases (plus follow-up of citations, expert recommendations, and checks for multiple publications about the same study). Searching identified 1,188 titles, and of these, 186 full-text articles were reviewed. Two authors extracted data from 45 articles meeting inclusion criteria. Published studies report few details about how mental health screens were administered, including how clinicians explain their purpose or confidentiality, or whether help was provided for language, literacy, or disability problems. Although they were not addressed directly in the studies reviewed, uptake and detection rates appeared to vary with means of administration. Screening framed as universal, confidential, and intended to optimize attention to patient concerns increased acceptability. Studies said little about how providers were taught to explore screen results. Screening increased referrals, but many still followed negative screens, in some cases because of parent concerns apparently not reflected by screen results but possibly stemming from screen-prompted discussions. Little research has addressed the process of engaging patients in mental health screening in pediatric primary care or how clinicians can best use screening results. The literature does offer suggestions for better clinical practice and research that may lead to improvements in uptake and outcome.
Article
Objective: Screening for adolescent depression is a quality indicator for pediatric care, and the parent-completed, 17-item Pediatric Symptom Checklist's internalizing (PSC-17P-INT) subscale has been validated for this purpose. The current study assessed the feasibility of PSC-17P-INT screening, the prevalence of risk on 2 consecutive PSC-17P-INTs, and rates of behavioral health (BH) service use before and after screening. Methods: The parent-report PSC-17 was completed on tablet devices before well-child visits (WCVs) with results instantaneously available to clinicians in the electronic health record. Billing data were used to identify adolescents with 2 consecutive WCVs and possible BH service utilization 6 months before and after their first screen. Results: In 2017, 1,068 adolescents (12-17 years old) were seen for a WCV, and 637 (59.6%) of them had one in 2018. Most (93.9%; N = 604) completed a PSC at both visits. Patients who scored positively on their first PSC-17P-INT were about 9 times more likely to receive subsequent BH services than patients who screened negative (24.3% vs 2.6%, χ2 = 59.65, p < 0.001). However, risk prevalence increased from the first (11.6%) to the second (14.9%) screen, and only 37.1% of at-risk patients remitted. Conclusion: The current study demonstrated that screening adolescents for depression using the PSC-17P-INT was feasible and associated with a significant increase in BH treatment rates. The study also demonstrated that the PSC could be used to track adolescents at risk for depression, found that most youth who screened positive remained at risk 1 year later, and supported recent quality guidelines calling for annual depression screening and follow-up for adolescents with depression.
Article
To determine the type of subsequent care received by children nonadherent with their next preventive visit and whether behavioral factors predict use of emergency or acute care in this population. Data on 1703 children (4-16 years) screened at a preventive visit with the Pediatric Symptom Checklist (PSC)/Youth-PSC were examined to determine subsequent preventive care adherence (10-18 months later). Then, nonadherent children were monitored to determine whether they returned to their medical home for acute care, delayed preventive care, or visited the emergency department (ED). Multivariate analyses were conducted to determine whether demographic and behavioral factors predicted return to either acute care or ED care site. Of the 461 children who were nonadherent with a second preventive care visit, most (85%) subsequently returned for acute, emergency, or delayed preventive care in the same medical system. Predictors of acute care or ED use included behavioral health risk characteristics (positive PSC, counseling, referral, parental concern), as well as adolescent age, self-pay and public insurance status, and living in lower socioeconomic communities. Pediatricians should consider acute care or ED visits as opportunities for mental health screening follow-up, and intervention in populations at high risk who miss preventive care.
Article
Full-text available
Introduction Neurodevelopmental delays and cognitive impairments are common in youth living with HIV. Unfortunately, in resource-limited settings, where HIV infection impacts millions of children, cognitive and neurodevelopmental disorders commonly go undetected because of a lack of appropriate assessment instruments and local expertise. Here, we present a protocol to culturally adapt and validate the Penn Computerized Neurocognitive Battery (PennCNB) and examine its validity for detecting both advanced and subtle neurodevelopmental problems among school-aged children affected by HIV in resource-limited settings. Methods and analysis This is a prospective, observational cohort study. The venue for this study is Gaborone, Botswana, a resource-limited setting with high rates of perinatal exposure to HIV and limited neurocognitive assessment tools and expertise. We aim to validate the PennCNB in this setting by culturally adapting and then administering the adapted version of the battery to 200 HIV-infected, 200 HIV-exposed uninfected and 240 HIV-unexposed uninfected children. A series of analyses will be conducted to examine the reliability and construct validity of the PennCNB in these populations. Ethics and dissemination This project received ethical approval from local and university Institutional Review Boards and involved extensive input from local stakeholders. If successful, the proposed tools will provide practical screening and streamlined, comprehensive assessments that could be implemented in resource-limited settings to identify children with cognitive deficits within programmes focused on the care and treatment of children affected by HIV. The utility of such assessments could also extend beyond children affected by HIV, increasing general access to paediatric cognitive assessments in resource-limited settings.
Article
Youth with obesity are at increased risk of psychosocial symptoms; however, little is known regarding the impact of paediatric weight management (PWM) on psychosocial health. The aim of the study was to investigate changes in psychosocial health among children who completed a 7-week PWM program. Participants aged 5 to 16 years with a BMI ≥85th percentile completed a 7-week, family-centred PWM program focused on health behaviour education, exercise and mentored goal setting. The Paediatric Symptom Checklist (PSC) was assessed via parent report to evaluate psychosocial symptoms before and after the program, and subscales were calculated for internalizing (PSC-IS), externalizing (PSC-ES) and attention symptoms (PSC-AS). At baseline, positive screen rates for psychosocial symptoms among the 317 patients included 16.1% for PSC, 14.1% for PSC-ES, 18.6% for PSC-IS and 12.3% for PSC-AS. Among program completers, total PSC scores improved in those with normal (p = 0.010) and elevated p < .001 psychosocial symptoms at baseline. Youth with positive screens for elevated PSC subscales improved their subscale scores, on average, and the majority reduced scores to below elevated levels for PSC (54.2%), PSC-ES (64.7%), PSC-IS (78.3%) and PSC-AS (64.7%). Improvements in PSC remained significant after adjusting for BMI changes during treatment, but BMI differed across PSC-change groups, including BMI increases among participants with PSC deterioration (0.33 ± 0.64 kg m−2) (P = 0.035) and BMI decreases among patients with no reliable PSC change (−0.26 ± 1.04 kg m−2) (P = 0.038) or reliable PSC improvement (−0.22 ± 0.74 kg m−2) (P = 0.025). Youth with positive screens for psychosocial symptoms can improve emotional and behavioural functioning during short-term PWM. Future research is needed to elucidate mechanisms and long-term outcome durability.
Article
Full-text available
Given the increasing interest in demonstrating effectiveness in psychiatric treatment, the current paper seeks to advance outcome measurement in child psychiatry by demonstrating how more informative analytic strategies can be used to evaluate treatment in a real world setting using a brief, standardized parent-report measure. Questionnaires were obtained at intake for 1294 patients. Of these, 695 patients entered treatment and 531 (74%) had complete forms at intake and follow-up. Using this sample, we analyzed the data to determine effect sizes, rates of reliable improvement and deterioration, and rates of clinically significant improvement. Findings highlighted the utility of these approaches for evaluating treatment outcomes. Further suggestions for improving outcome measurement and evaluation are provided.
Article
Validated behavioral health (BH) screens are recommended for use at well-child visits. This study aimed to explore how pediatricians experience and use these screens for subsequent care decisions in primary care. The study took place at 4 safety net health centers. Fourteen interviews were conducted with pediatricians who were mandated to use validated BH screens at well-child visits. Interview questions focused on key domains, including clinic BH context, screening processes, assessment of screening scores, and decision making about referral to mental health services. Qualitative analysis used the Framework Approach. A variety of themes emerged: BH screens were well accepted and valued for the way they facilitated discussion of mental health issues. However, screening results were not always used in the way that instrument designers intended. Providers' beliefs about the face validity of the instruments, and their observations about performance of instruments, led to discounting scored results. As a result, clinical decisions were made based on a variety of evidence, including individual item responses, parent or patient concerns, and perceived readiness for treatment. Additionally, providers, although interested in expanding their mental health discussions, perceived a lack of time and of their own skills to be major obstacles in this pursuit. Screens act as important prompts to stimulate discussion of BH problems, but their actual scored results play a variable role in problem identification and treatment decisions. Modifications to scheduling policies, additional provider training, and enhanced collaboration with mental health professionals could support better BH integration in pediatric primary care.
Chapter
Screening is the process of measuring and detecting the signs and symptoms of a disorder before the disorder has progressed. While the evidence on the effectiveness and quality of mental health screening tools is advancing, the application of these tools into standard clinical practice has lagged behind due to implementation barriers in primary care settings. The goal of this chapter is to address the range of screening tools for specific patient populations and to address the barriers for incorporating these standardized tools into primary care. This chapter provides descriptions of reliable and valid screening tools for preschoolers, school-age children, adolescents, adults and older adults—men and women—and older adults. There are also descriptions of how screening tools are used in a clinical setting by defining roles and responsibilities for team members, identifying practice management and financial considerations, and describing relevant opportunities for quality improvement.
Article
Objective: This study discusses the impact of mental health screening in pediatric primary care on the management of mental health concerns. Methods: Youth aged 11 years and their parents completed the Pediatric Symptom Checklist and chart reviews were used to gather information about discussion of mental health concerns and connection with mental health services. The study design was a post-intervention study with a concurrent comparison group of youth aged 12 years who were not offered a screening. The χ(2) or Fisher's exact tests and logistic regression were used to compare groups on outcome variables. Results: Parents who completed a mental health screening for their child were more likely to be referred and attend mental health services, attend a psychiatrist appointment, and discuss their concerns with the primary care provider compared with the comparison group. Conclusions: Screening by parents improves detection of problems and fosters conversations with providers and subsequent connection with services.
Article
Purpose Although mental health screening is recommended for adolescents, little is known about the predictors of referral to mental health services or engagement in treatment. We examined predictors of mental health referral from primary care and service use for commercially insured youth who had been screened using the Pediatric Symptom Checklist or Youth-Pediatric Symptom Checklist. Methods A retrospective chart review was conducted of commercially insured patients 14–17 years of age who were newly identified by the Pediatric Symptom Checklist or Youth-Pediatric Symptom Checklist at a well-child visit. Comparisons were made with propensity-matched negative adolescents meeting the same criteria. Bivariate analyses were conducted to examine differences between positives and negatives and between referred and nonreferred positives. Logistic regression analyses were performed to assess predictors of mental health referral for positive youth. Results Medical records of 117 positive and 110 negative youth were examined. Compared with negative youth, positive youth were significantly more likely to be referred for mental health treatment (p < .0001) and receive specialty mental health services (p < .0001). Of the positives, 54% were referred for mental health care and 67% of them accepted. However, only 18% completed a face-to-face mental health visit in the next 180 days. Pediatric Symptom Checklist score (odds ratio, 1.21; confidence interval, 1.03–1.42), parental or personal concern (odds ratio, 10.87; confidence interval, 2.70–43.76), and having depressive symptoms (odds ratio, 9.18; confidence interval, 1.49–56.60) were predictive of referral. Conclusions Despite identification after behavioral health screening, limited treatment engagement by referred patients persists. Primary care physicians and mental health specialists must enhance their efforts to engage and monitor identified patients.
Article
Full-text available
To review recent health policies related to measuring child health care quality, the selection processes of national child health quality measures, the nationally recommended quality measures for child mental health care and their evidence strength, the progress made toward developing new measures, and early lessons learned from these national efforts. Methods used included description of the selection process of child health care quality measures from 2 independent national initiatives, the recommended quality measures for child mental health care, and the strength of scientific evidence supporting them. Of the child health quality measures recommended or endorsed during these national initiatives, only 9 unique measures were related to child mental health. The development of new child mental health quality measures poses methodologic challenges that will require a paradigm shift to align research with its accelerated pace.
Article
Barriers to conducting standardized behavioral health screening within pediatric primary care settings include engaging youth and families, limited time available for this activity, and difficulties related to obtaining behavioral health consultation and treatment from specialists. Child and adolescent psychiatrists may assist pediatric primary care practices with engaging youth and families around screening by assisting with identifying rating scales that have good psychometric characteristics across multiple languages and are validated in diverse samples and available within the public domain. Additionally, they may partner with pediatric primary care professionals to assist with optimizing screening workflows and linkage to specialized services.
Article
Full-text available
The Pediatric Symptom Checklist (PSC) is a widely-used, parent-completed measure of children's emotional and behavioral functioning. Previous research has shown that the PSC and its subscales are generally responsive to patient progress over the course of psychiatric treatment. In this naturalistic study, we examined the performance and utility of the five-item PSC Internalizing Subscale (PSC-IS) as an assessment of routine treatment in outpatient pediatric psychiatry. Parents and clinicians of 1,593 patients aged 17 or younger completed standardized measures at intake and three-month follow-up appointments. Comparisons between PSC-IS scores and clinician-reported diagnoses, internalizing symptoms, and overall functioning showed acceptable levels of agreement. Change scores on the PSC-IS were also larger among patients with internalizing diagnoses than those with non-internalizing diagnoses. As a brief measure of internalizing symptoms, the PSC may be particularly useful to mental health clinicians treating youth with depression and anxiety as a quality assurance or treatment outcome measure.
Article
Full-text available
Psychosocial problems cause much of the morbidity among children, and their frequency of presentation in primary care is growing. How is primary care treatment of children's psychosocial problems affected by child symptoms, physician training, practice structure, insurance, physician/patient relationship, and family demographics? Questionnaire study of treatment of psychosocial problems during office visits by children. At total of 401 primary care offices from 44 US states, Puerto Rico, and Canada. From 21 150 children seen in office visits, we selected children with an identified psychosocial problem but who were not already receiving specialty mental health services (n = 2618 children). Clinicians' decisions to counsel families, to refer children to mental health specialists, or to prescribe medication. The treatment choices of primary care clinicians (PCCs) were generally independent of patients' demographics or insurance status. Clinicians' training, beliefs about mental health, and practice structure had no effect on treatment choices. However, clinicians seeing their own patients were more likely to prescribe medications for attention problems. The clinician's perception about whether the parent agreed with the treatment choice was important for every treatment modality. Counseling and referral were more common and medication was less common when a problem was newly recognized at the visit. Structural factors such as practice type, insurance coverage, and physician training were less important for treatment than were process factors, such as whether the visit was a psychosocial problem visit, whether the problem was newly or previously recognized, and whether the family and clinician were familiar with each other and in accord about treatment.
Article
Full-text available
To assess the degree to which physicians and nurses working in preventive child health care (child health professionals [CHPs]) identify and manage psychosocial problems in children, and to determine its association with parent-reported behavioral and emotional problems, sociodemographic factors, and general and mental health history of children. The CHPs examined the child and interviewed parents and child during their routine health assessments. The parents completed the Child Behavior Checklist. Nineteen child health care services across the Netherlands, serving nearly all school-aged children routinely. Of 4970 children aged 5 through 15 years, eligible for a routine health assessment, 4480 (90.1%) participated. Identification and management of psychosocial problems by CHPs. In 25% of all children, CHPs identified 1 or more psychosocial problems. One in 5 identified children were referred for further diagnosis and treatment. Identification of psychosocial problems and subsequent referral were 6 times more likely in children with serious parent-reported problem behavior according to the Child Behavior Checklist total problem score (8% of total sample). However, CHPs identified no psychosocial problems in 43% of these children and therefore undertook no action. Other child factors associated with CHPs' identification and referral were past treatment for psychosocial problems, life events, and academic problems. After adjustment for these, sociodemographic characteristics did not predict referral. The CHPs identify psychosocial problems in school-aged children frequently and undertake actions for most of them. Screening for psychosocial problems may be a promising option to reduce these problems, but accurate identification should be enhanced.
Article
Full-text available
In a recent national survey, the prevalence of psychiatric disorder in children and adolescents in Great Britain was more than 9%.1 Parents and doctors commonly think that these disorders are transient, but longitudinal studies show otherwise.2 We followed up children from the national survey to examine persistence in a large sample of children in Britain.1
Article
Full-text available
This longitudinal community study assessed the prevalence and development of psychiatric disorders from age 9 through 16 years and examined homotypic and heterotypic continuity. A representative population sample of 1420 children aged 9 to 13 years at intake were assessed annually for DSM-IV disorders until age 16 years. Although 3-month prevalence of any disorder averaged 13.3% (95% confidence interval [CI], 11.7%-15.0%), during the study period 36.7% of participants (31% of girls and 42% of boys) had at least 1 psychiatric disorder. Some disorders (social anxiety, panic, depression, and substance abuse) increased in prevalence, whereas others, including separation anxiety disorder and attention-deficit/hyperactivity disorder (ADHD), decreased. Lagged analyses showed that children with a history of psychiatric disorder were 3 times more likely than those with no previous disorder to have a diagnosis at any subsequent wave (odds ratio, 3.7; 95% CI, 2.9-4.9; P<.001). Risk from a previous diagnosis was high among both girls and boys, but it was significantly higher among girls. Continuity of the same disorder (homotypic) was significant for all disorders except specific phobias. Continuity from one diagnosis to another (heterotypic) was significant from depression to anxiety and anxiety to depression, from ADHD to oppositional defiant disorder, and from anxiety and conduct disorder to substance abuse. Almost all the heterotypic continuity was seen in girls. The risk of having at least 1 psychiatric disorder by age 16 years is much higher than point estimates would suggest. Concurrent comorbidity and homotypic and heterotypic continuity are more marked in girls than in boys.
Article
Full-text available
Although children with emotional or behavioural problems are at increased risk of future problems, knowledge of factors associated with persistence and change in child problems, once these problems exist, is limited. Using repeated measures analyses of variance, the present study investigated the association of parental problem recognition, professional and informal service use, and sociodemographic factors with change in child problems over a one-year period, in a sample of 360 children and adolescents with emotional and behavioural problems. Higher overall problem levels were found in children (aged 4-11 years at baseline) versus adolescents (aged 12-17 years), in boys, and in children with less educated parents, which indicates the need to address preventive actions at these groups. Although rates of service use were low, children who had been in contact with general practitioners or mental health services had higher overall problem levels, suggesting that children who need it most end up receiving professional care. Although child emotional and behavioural problems decreased significantly over time, this change was not associated with utilisation of professional or informal services. Our findings imply the need for methodologically sound research into the effectiveness of professional and informal services for child emotional and behavioural problems.
Article
Full-text available
The goals were to examine factors related to positive Pediatric Symptom Checklist scores in an urban practice and to examine the relative contribution of parental/personal concern about emotional and behavioral problems to mental health problem identification. Annual screening using the Pediatric Symptom Checklist was implemented in Cambridge Pediatrics (Cambridge, MA). A social worker was colocated in the clinic to provide therapeutic interventions for patients. A sample of 1668 screened patients between 4 years 11 months and 19 years of age was used for analysis. Bivariate and multivariate analyses were conducted to determine factors predictive of positive Pediatric Symptom Checklist scores, including demographics, socioeconomic indicators, enrollment in counseling, and parental/personal concern. Parental/personal concern, counseling, and positive Pediatric Symptom Checklist scores were examined to determine their efficacy as screening methods. Six percent of the population had positive Pediatric Symptom Checklist scores. There were statistically significant relationships between a positive score and being in counseling, parental/personal concern, having public insurance, and living in an area with median household incomes of less than 50,000 dollars. Parental/personal concern was 40% sensitive for a positive score. A positive Pediatric Symptom Checklist score with or without parental/personal concern identified 3.8% of the population; parental/personal concern with or without a positive Pediatric Symptom Checklist score identified 4.5%. Mental health screening can be effectively implemented in a pediatric practice. Colocated mental health professionals provide additional support. The combination of a screening tool and questions about parental/personal concern and present counseling can provide critical information about a child's mental health.
Article
Full-text available
Our goal was to evaluate the feasibility and impact of an intervention on the management of family psychosocial topics at well-child care visits at a medical home for low-income children. A randomized, controlled trial of a 10-item self-report psychosocial screening instrument was conducted at an urban hospital-based pediatric clinic. Pediatric residents and parents were randomly assigned to either the intervention or control group. During a 12-week period, parents of children aged 2 months to 10 years presenting for a well-child care visit were enrolled. The intervention components included provider training, administration of the family psychosocial screening tool to parents before the visit, and provider access to a resource book that contained community resources. Parent outcomes were obtained from postvisit and 1-month interviews, and from medical chart review. Provider outcomes were obtained from a self-administered questionnaire collected after the study. Two hundred parents and 45 residents were enrolled. Compared with the control group, parents in the intervention group discussed a significantly greater number of family psychosocial topics (2.9 vs 1.8) with their resident provider and had fewer unmet desires for discussion (0.46 vs 1.41). More parents in the intervention group received at least 1 referral (51.0% vs 11.6%), most often for employment (21.9%), graduate equivalent degree programs (15.3%), and smoking-cessation classes (14.6%). After controlling for child age, Medicaid status, race, educational status, and food stamps, intervention parents at 1 month had greater odds of having contacted a community resource. The majority of residents in the intervention group reported that the survey instrument did not slow the visit; 54% reported that it added <2 minutes to the visit. Brief family psychosocial screening is feasible in pediatric practice. Screening and provider training may lead to greater discussion of topics and contact of community family support resources by parents.
Article
Full-text available
We examined child and parent outcomes of training providers to engage families efficiently and to reduce common symptoms of a range of mental health problems and disorders. Training involved three 1-hour discussions structured around video examples of family/provider communication skills, each followed by practice with standardized patients and self-evaluation. Skills targeted eliciting parent and child concerns, partnering with families, and increasing expectations that treatment would be helpful. We tested the training with providers at 13 sites in rural New York, urban Maryland, and Washington, DC. Children (5-16 years of age) making routine visits were enrolled if they screened "possible" or "probable" for mental disorders with the Strengths and Difficulties Questionnaire or if their provider said they were likely to have an emotional or behavioral problem. Children and their parents were then monitored for 6 months, to assess changes in parent-rated symptoms and impairment and parent symptoms. Fifty-eight providers (31 trained and 27 control) and 418 children (248 patients of trained providers and 170 patients of control providers) participated. Among the children, 72% were in the possible or probable categories. Approximately one half (54%) were white, 30% black, 12% Latino, and 4% other ethnicities. Eighty-eight percent (367 children) completed follow-up monitoring. At 6 months, minority children cared for by trained providers had greater reduction in impairment (-0.91 points) than did those cared for by control providers but no greater reduction in symptoms. Seeing a trained provider did not have an impact on symptoms or impairment among white children. Parents of children cared for by trained providers experienced greater reduction in symptoms (-1.7 points) than did those cared for by control providers. Brief provider communication training had a positive impact on parent mental health symptoms and reduced minority children's impairment across a range of problems.
Article
Suicide is the third leading cause of death for adolescents 15 to 19 years old. Pediatricians can help prevent adolescent suicide by knowing the symptoms of depression and other presuicidal behavior. This statement updates the previous statement by the American Academy of Pediatrics and assists the pediatrician in the identification and management of the adolescent at risk for suicide. The extent to which pediatricians provide appropriate care for suicidal adolescents depends on their knowledge, skill, comfort with the topic, and ready access to appropriate community resources. All teenagers with suicidal symptoms should know that their pleas for assistance are heard and that pediatricians are willing to serve as advocates to help resolve the crisis.
Article
The Pediatric Symptom Checklist (PSC) is a brief, well-validated parent-report questionnaire designed to detect psychosocial dysfunction in school-age children during pediatric primary care visits. This study assessed the utility of the PSC when completed by children (PSC-Y) ages 9-14 in a public school when parents are not available (n = 173). The PSC-Y identified 20% of children as having psychosocial problems, a rate similar to other low-income samples. When compared with teacher ratings of attention and behavior problems, the PSC-Y showed a sensitivity of 94% and a specificity of 88%. The PSC-Y correlated significantly with teacher and parent measures of child dysfunction, and with child-reported symptoms of depression and anxiety. Three quarters of the children identified by the PSC-Y were not identified by parents on the PSC. These children had impairment on all other measures, but fewer than one in five had received mental health services, suggesting the PSC-Y identified children with unmet mental health needs. The PSC-Y has the potential to be a rapid, easily administered tool for large-scale mental health screening in schools.
Article
This study examined the routine implementation of the Pediatric Symptom Checklist (PSC), a brief questionnaire which screens for psychosocial dysfunction in school-aged children in an outpatient pediatric practice. Results indicated that the PSC was well-accepted by parents and adequately tolerated by busy clinic staff. When the PSC was included as part of the standard procedure for well-child visits, the referral rate for psychosocial problems due to positive PSC scores rose to 12% from the clinic baseline referral rate of 1.5%, a significant increase (P < .01). Half of the children who screened positive on the PSC had not been previously identified by their pediatricians as having psychosocial problems, and more than half had never received any psychological treatment. When implementation of the PSC was discontinued, the referral rate fell to 2%, a rate similar to baseline. The findings suggest that it is possible to incorporate the PSC into routine pediatric practice and that the PSC can help pediatricians identify and better serve children experiencing psychosocial difficulties. The study also suggests that further work is needed to understand the barriers to ongoing implementation.
Article
Examined the validity of the Pediatric Symptom Checklist (PSC), a brief parent-completed psychosocial screening questionnaire, in a sample of 166 students from a public middle school. Positive screening on the parent PSC was significantly associated with independent ratings by the students' guidance counselor and teachers of the need for regular counseling; any academic failure during the next 2 years; and PSCs competed by the students about themselves. Most students who screened positive on the parent PSC were found to have significant problems in at least one of the above areas. The PSC also identified a group of students whose difficulties were previously unknown to school personnel. For pediatric psychologists, guidance counselors, and pediatricians who need to identify middle-school students with serious psychosocial problems, the PSC appears to be a valid and useful first-stage screening instrument.
Article
The Pediatric Symptom Checklist (PSC) is a brief screening questionnaire designed to help pediatricians in busy office practice select children who are likely to have psychosocial difficulties and thus could benefit from further evaluation. We report two preliminary validation studies that indicate that PSC correlates well with the Childhood Behavior Checklist, a longer, well-validated questionnaire, and most children referred for psychiatric evaluation score above the PSC cutoff score. Developing a valid and practical psychosocial screening procedure for office practice is methodologically difficult but highly relevant to clinical practice.
Article
To examine the usefulness of the Pediatric Symptom Checklist (PSC) as the psychosocial screening measure to meet federal Medicaid/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) standards in a low-income Hispanic community. Three hundred seventy-nine children (aged 6 to 16 years) were screened with the PSC in a 10-month period during well child visits to three clinics in Ventura and San Mateo counties in California. The PSC was available in English and Spanish and was administered both in written (paper-and-pencil) and oral formats. Follow-up services were provided for children identified as needing evaluation. The Cronbach alpha was high (r = 0.91) for the PSC in the whole sample and virtually identical for English, Spanish, oral, and written formats. All the PSC items were significantly associated with total score on the PSC in English, Spanish, oral, and written formats. Overall, the PSC identified 10.6% of the sample as at risk for psychosocial problems. Thirty-six children (9.5% of sample) were referred for mental health follow-up. Public health data from Ventura County showed a statistically significant increase in referrals for psychologic problems during the study period in two locations using the PSC: from 0.5% to 2.9% of the school-aged children seen. The PSC provides a feasible, well-accepted method for screening for psychosocial problems during EPSDT examinations of school-aged children. Psychosocial screening using a validated instrument such as the PSC, as well as increased efforts to refer positive screening results, track outcomes, and assess cost benefits should be essential requirements in capitated Medicaid approaches to caring for poor children.
Article
We reviewed the current status of behavior screening methods, such as parental questionnaires, for identifying behavioral problems in children seen in pediatric settings. Information is organized around basic criteria for implementing screening procedures. We conclude that although use of parent-completed questionnaires, such as the Child Behavior Checklist and the Pediatric Symptom Checklist, can increase identification of child behavioral dysfunction in pediatric settings, it is unclear whether screening will cause a change in physician behaviors necessary to improve child functional outcomes. Clinical and research implications are discussed.
Article
School-based health centers (SBHC) have substantial potential to improve the recognition and treatment of adolescents' mental health problems. This study was undertaken as a quality improvement project to evaluate utility of the Pediatric Symptom Checklist when completed by youth (PSC-Y) among 383 adolescents seen at a SBHC, and the extent to which identification of psychosocial dysfunction and referral to mental health services improved academic functioning. Adolescents identified by the PSC-Y were significantly more likely to be insured by Medicaid, be a teen-age parent, and to have higher rates of absenteeism and tardiness in comparison to those not identified. Adolescents identified with the PSC-Y who were referred to mental health services significantly decreased their rates of absences and tardiness. Study results provide support for the utility of psychosocial screening and referral in the SBHC environment in facilitating recognition and treatment of adolescent mental health problems and improving student academic functioning.
Article
As pressure increases for the demonstration of effective treatment for children with mental disorders, it is essential that the field has an understanding of the evidence base. To address this aim, the authors searched the published literature for effective interventions for children and adolescents and organized this review as follows: (1) prevention; (2) traditional forms of treatment, namely outpatient therapy, partial hospitalization, inpatient treatment, and psychopharmacology; (3) intensive comprehensive community-based interventions including case management, home-based treatment, therapeutic foster care, and therapeutic group homes; (4) crisis and support services; and (5) treatment for two prevalent disorders, major depressive disorder and attention-deficit hyperactivity disorder. Strong evidence was found for the treatment of attention-deficit hyperactivity disorder, depression, anxiety, and disruptive behavior disorders. Guidance from the field relevant to moving the evidence-based interventions into real-world clinical practice and further strengthening the research base will also need to address change in policy and clinical training.
Article
To determine which area-based socioeconomic measures, at which level of geography, are suitable for monitoring socioeconomic inequalities in sexually transmitted infections (STIs), tuberculosis (TB), and violence in the United States. Cross-sectional analysis of public health surveillance data, geocoded and linked to area-based socioeconomic measures generated from 1990 census tract, block group, and ZIP Code data. We included all incident cases among residents of either Massachusetts (MA; 1990 population = 6016425) or Rhode Island (RI; 1990 population = 1003464) for: STIs (MA: 1994-1998, n = 26535 chlamydia, 7464 gonorrhea, 2619 syphilis; RI: 1994-1996, n = 4473 chlamydia, 1256 gonorrhea, 305 syphilis); TB (MA: 1993-1998, n = 1793; RI: 1985-1994, n = 576), and non-fatal weapons related injuries (MA: 1995-1997, n = 6628). Analyses indicated that: (a). block group and tract socioeconomic measures performed similarly within and across both states, with results more variable for the ZIP Code level measures; (b). measures of economic deprivation consistently detected the steepest socioeconomic gradients, considered across all outcomes (incidence rate ratios on the order of 10 or higher for syphilis, gonorrhea, and non-fatal intentional weapons-related injuries, and 7 or higher for chlamydia and TB); and (c). results were similar for categories generated by quintiles and by a priori categorical cut-points. Supplementing U.S. public health surveillance systems with census tract or block group area-based socioeconomic measures of economic deprivation could greatly enhance monitoring and analysis of social inequalities in health in the United States.
Article
To identify factors associated with positive scores on a brief psychosocial screening tool with subscales for internalizing, externalizing, and attention problems. Parents of 2028 children between the ages of 7 and 15 years seen in a sample of 8 primary care practices in the Minneapolis-St Paul metropolitan area completed a brief questionnaire that included the 17-item Pediatric Symptom Checklist (PSC), demographic information, and the reason for the child's visit to the clinic. Overall, 22% of the youth had at least 1 positive PSC-17 subscale or a positive PSC-17 total score. Twelve percent scored positive on the internalizing subscale, 10% on the externalizing subscale, 7% on the attention subscale, and 11% had a positive PSC-17 total score. Although boys were more likely than girls to score positive on the attention and aggression subscales, boys and girls were equally likely to have a positive score on the depression subscale. Children not living with both biological parents and those with a household member receiving public assistance were significantly more likely to show psychosocial dysfunction. Controlling for demographic characteristics, patients presenting for an illness-related or injury visit were more likely to score positive on the screen than those presenting for a routine well-child visit (odds ratio: 1.46; 95% confidence interval: 1.07-1.98). Clinicians will miss opportunities to identify emotional and behavioral disorders among children and adolescents who may be at a higher risk if they limit psychosocial screening to health supervision visits. Further research is needed to identify effective strategies for using primary care for recognizing, diagnosing, and treating mental health disorders in children and adolescents.
Article
It is widely believed that only a minority of vulnerable children and adolescents receive any mental health services. Although health care disparities associated with sociodemographic characteristics are well known, almost no information exists about another potentially important source of disparity for children: How does state of residence affect mental health service use? Observational analysis was conducted using the 1997 and 1999 waves of the National Survey of America's Families (N = 45 247 children aged 6-17), a population survey fielded in 13 states and a smaller geographically dispersed sample. We studied 4 dependent variables: 1) use of any mental health services and number of visits among users; 2) need for mental health care, based on 6 items from the Child Behavior Checklist; 3) unmet need (no services among children with identified need); and 4) need among users of mental health services. Use of any mental health care differs >2-fold across states, ranging from 5% in California and Texas to >10% in Colorado and Massachusetts. The variation across states in service use and unmet need exceeds the differences across racial/ethnic groups or family income. For example, the odds ratio of unmet need in California versus Massachusetts is 3.04, compared with 2.33 between Hispanic and white children. Differences in population characteristics across states do not explain much of the observed geographic variation in mental health related outcomes for children. Perhaps the most disconcerting finding is that the differences in use are not paralleled by differences in need. Overall, there is no apparent relationship between levels of need and use of services across states. As a general rule, states with high rates of services do not have low levels of need or vice versa, although that situation exists. Alabama and Texas, for example, have higher rates of need and lower rates of use than the nation as a whole, whereas Washington state displays the opposite pattern. Even with the similar levels of need and service use, states differ in the effectiveness of their delivery system. Alabama and Mississippi have high rates of need and low levels of use, but rates of unmet need are not significantly higher in those 2 states than in the nation, whereas California, Florida, and Texas have the highest rates of unmet need. In California and Texas, children from high-income families are more likely to receive some mental health services than children from low-income families. In Alabama and Mississippi, as well as in the states with the lowest rates of unmet need (Colorado, Massachusetts, and Minnesota), the opposite is true: children from low-income families are much more likely to receive any mental health service than children from high-income families. Large differences from the national average across states in service use and unmet need are the rule, rather than the exception. National averages obscure large differences that can exceed the effects of race/ethnicity or income. The differences in the rates of use or unmet need are not driven by differences in the racial/ethnic or socioeconomic makeup across states but more likely are the result of differences in state policies and health care market characteristics. These state policies and health care market characteristics can interact with sociodemographic characteristics and affect how effectively resources are used. For states such as California and Texas that have the lowest rates of mental health service use, it may be less important to raise the rates of service use than to deliver them to the children with the highest need, predominantly black and Hispanic children and children in low-income families.
Article
To examine the longitudinal course of subthreshold and full-criteria child psychiatric disorders. Nine hundred ninety-six children, aged 4 to 9 years, from a representative sample of pediatric primary care practices participated in a 1-year follow-up in 1989-1990. Parent interviews included the Diagnostic Interview Schedule for Children, measures of psychosocial problems, stress, social support, possible child abuse, and sociodemographics. The initial prevalence of full and subthreshold disorders was 18.8% and 14.0%, respectively. Full and subthreshold disorders were associated with impairment. Approximately 37% of children with full disorders had persistent disorders. Persistence was more common among boys than girls, particularly when comorbidity was present. Children with initial subthreshold disorders only were five times more likely than those without disorder to develop a full disorder. Persistence of full disorders was associated with high initial symptoms. Among boys, persistence was linked to possible child abuse, whereas among girls it was associated with full externalizing disorders that were accompanied by subthreshold internalizing disorders. Intervention may be particularly crucial when a high number of symptoms and/or both internalizing and externalizing problems are present. Underscoring the importance of family-centered rather than child-centered interventions, boys whose parents reported possible child abuse were more likely to have persistent disorders.
Article
There has been a strong push toward the recognition and treatment of children with behavioral health problems by primary care pediatricians. This study was designed to assess the extent to which a sample of primary care pediatricians diagnose and treat behavioral health problems and to identify factors that may contribute to their behavioral health practice. A standard interview was conducted with 47 pediatricians who work in primary care settings in a predominantly urban setting in North Carolina. Pediatricians' responses to questions about the estimated percentage of children in their practice with a behavioral health disorder, tools used to make diagnoses, frequent and infrequent diagnoses made, comfort level with making a diagnosis, reasons for not making a diagnosis, use of psychotropic medications, types of nonmedication interventions provided, educational background, and needs involving behavioral health issues were evaluated. Pediatricians estimated that the average percentage of children in their practices with a behavioral health disorder was 15%. The study did not find significant differences in perceptions related to time in practice or gender of the pediatric provider. The most frequent behavioral health diagnosis was attention-deficit/hyperactivity disorder (ADHD), and the majority incorporated behavioral questionnaires, expressed a high level of comfort with the diagnosis, and frequently or occasionally prescribed stimulants. Variability was noted in both practice and comfort for other behavioral health disorders. Slightly fewer than half of the pediatricians frequently diagnosed anxiety and depression. Those who make these diagnoses commonly incorporated questionnaires and reported frequent or occasional use of selective serotonin reuptake inhibitors. Comfort in making the diagnosis of anxiety was highly associated with use of selective serotonin reuptake inhibitors. The vast majority (96%) of pediatricians provided nonmedication interventions, including supportive counseling, education for coping with ADHD, behavior modification, and/or stress management. Diagnosis and treatment of severe behavioral health disorders were infrequent throughout the pediatric practices. Areas of greatest educational interest included psychopharmacology, diagnosis and treatment of depression and anxiety, and updates on ADHD. The majority of pediatric providers did not identify a need for education about several high-prevalence disorders that they do not frequently diagnose or treat, including conduct disorder and substance abuse. Pediatricians in this sample frequently diagnosed and treated ADHD. For all other behavioral health disorders, pediatricians reported variability in both comfort and practice. They frequently provided both pharmacologic and nonpharmacologic treatments for children and adolescents with mild to moderate behavioral health disorders but not for severe disorders. Although they identified needs for additional education for anxiety and depression, the majority did not identify educational needs for several high-prevalence behavioral health disorders, including conduct disorder and substance abuse.
Article
To review recent progress in child and adolescent psychiatric epidemiology in the area of prevalence and burden. The literature published in the past decade was reviewed under two headings: methods and findings. Methods for assessing the prevalence and community burden of child and adolescent psychiatric disorders have improved dramatically in the past decade. There are now available a broad range of interviews that generate DSM and ICD diagnoses with good reliability and validity. Clinicians and researchers can choose among interview styles (respondent based, interviewer based, best estimate) and methods of data collection (paper and pencil, computer assisted, interviewer or self-completion) that best meet their needs. Work is also in progress to develop brief screens to identify children in need of more detailed assessment, for use by teachers, pediatricians, and other professionals. The median prevalence estimate of functionally impairing child and adolescent psychiatric disorders is 12%, although the range of estimates is wide. Disorders that often appear first in childhood or adolescence are among those ranked highest in the World Health Organization's estimates of the global burden of disease. There is mounting evidence that many, if not most, lifetime psychiatric disorders will first appear in childhood or adolescence. Methods are now available to monitor youths and to make early intervention feasible.
There is increasing demand for physicians in pediatric settings to address not only the physical but also the psychosocial health of their child and adolescent patients. Brief interventions (BIs), and in particular Motivational interviewing (MI), offer an efficient means of targeting behavioral, developmental, and social problems within the context of pediatric practice. This review addresses the patient-centered care foundation of and empirical support for brief pediatric interventions, including educational and media-based interventions, MI-based prevention and intervention with health risk behaviors, procedural pain control, and adherence to treatment recommendations. In addition, developmental considerations and future directions for BI research in pediatric practice are summarized.
Article
Suicide is the third-leading cause of death for adolescents 15 to 19 years old. Pediatricians can take steps to help reduce the incidence of adolescent suicide by screening for depression and suicidal ideation and behavior. This report updates the previous statement of the American Academy of Pediatrics and is intended to assist the pediatrician in the identification and management of the adolescent at risk of suicide. The extent to which pediatricians provide appropriate care for suicidal adolescents depends on their knowledge, skill, comfort with the topic, and ready access to appropriate community resources. All teenagers with suicidal thoughts or behaviors should know that their pleas for assistance are heard and that pediatricians are willing to serve as advocates to help resolve the crisis.
Article
Childhood psychosocial problems have profound effects on development, functioning, and long-term mental health. The pediatrician is often the only health professional who regularly comes in contact with young children, and it is recommended that health care supervision should include care of behavioral and emotional issues. However, it is unknown whether pediatricians believe they should be responsible for this aspect of care. Our objective was to report the proportion of physicians who agree that pediatricians should be responsible for identifying, treating/managing, and referring a range of behavioral issues in their practices, and to examine the personal physician and practice characteristics associated with agreeing that pediatricians should be responsible for treating/managing 7 behavioral issues. The 59th Periodic Survey of members of the American Academy of Pediatrics was sent to a random sample of 1600 members. The data that are presented are based on the responses of 659 members in current practice and no longer in training who completed the attitude questions. More than 80% of respondents agreed that pediatricians should be responsible for identification, especially for attention-deficit/hyperactivity disorder (ADHD), eating disorders, child depression, child substance abuse, and behavior problems. In contrast, only 59% agreed that pediatricians were responsible for identifying learning problems. Seventy percent thought that pediatricians should treat/manage ADHD; but for other conditions, most thought that their responsibility should be to refer. Few factors were consistently associated with higher odds of agreement that pediatricians should be responsible for treating/managing these problems, except for not spending their professional time exclusively in general pediatrics. These data suggest that pediatricians think that they should identify patients for mental health issues, but less than one-third agreed that it is their responsibility to treat/manage such problems, except for children with ADHD. Those not working exclusively in general pediatrics were more likely to agree that pediatricians should be responsible for treating and managing children's mental health problems.
Article
This chapter reviews recent developments in the analysis of categorical and contingency-table data. The first portion examines developments in model testing and selection. The second portion examines work on models for the structure of dependence. These include log-linear parameter models, models for latent classes, models for missing observations, numerical-scale-based association and correlation models (such as correspondence analysis), the treatment of ordered categories, and models for marginal distributions.
Change in children's emotional and behavioral problems over a one-year period
  • M Zwannswijk
  • Pf Verhaak
  • J Ende
Zwannswijk M, Verhaak PF, van der Ende J, et al. Change in children's emotional and behavioral problems over a one-year period. Eur Child Adolesc Psychiatry. 2006;15:127–131.
Bright Futures in Practice: Mental Health Volume I. Practice Guide
  • Patel M Bp Jellinek
  • Froehle
  • Mc
Jellinek M, Patel BP, Froehle MC, eds. Bright Futures in Practice: Mental Health Volume I. Practice Guide. Arlington, Va: National Center for Education in Maternal and Child Health; 2002.
Brief intervention and motiva-tional interviewing with children, adolescents, and their parents in pediatric health care settings
  • Erickson
  • Sj
  • M Gerstle
  • Feldstein
  • Sw
Erickson SJ, Gerstle M, Feldstein SW. Brief intervention and motiva-tional interviewing with children, adolescents, and their parents in pediatric health care settings. Arch Pediatr Adolesc Med. 2005;159: 1173–1180.
Available at: http://psc. partners.org/psc_bibliography.htm. Accessed
  • Pediatric Symptom Checklist
  • Bibliography
Pediatric Symptom Checklist. Bibliography. Available at: http://psc. partners.org/psc_bibliography.htm. Accessed May 10, 2008.
Bright Futures in Practice: Mental Health. Volume II Tool Kit. Arlington, Va: National Center for Education in Maternal and Child Health
  • M Jellinek
  • B P Patel
  • M C Froehle
Jellinek M, Patel BP, Froehle MC, eds. Bright Futures in Practice: Mental Health. Volume II Tool Kit. Arlington, Va: National Center for Education in Maternal and Child Health 2002. Available at: http://www.brightfutures.org/mentalhealth/pdf/professionals/ ped_sympton_chklst.pdf. Accessed January 15, 2009.
Available at: http://www.ma ssresources.org/pages.cfm?contentID=50&pageID=13&Subpages= yes
  • Uncompensated Care
  • Pool
Uncompensated Care Pool (UCP). Available at: http://www.ma ssresources.org/pages.cfm?contentID=50&pageID=13&Subpages= yes. Accessed February 5, 2008.
Change in children's emotional and behavioral problems over a one-year period
  • Zwannswijk
Revision: recommendations for Preventive Pediatric Health Care
Identifying psychosocial dysfunction in school-age children: the Pediatric Symptom Checklist as a self-report measure
  • Pagano
Brief intervention and motivational interviewing with children, adolescents, and their parents in pediatric health care settings
  • Erickson