Psychosocial Problems and Screening
dysfunction, considered a "new morbidity" twenty-five years ago, has become
as the most common, chronic condition of children and adolescents.1,
2 Epidemiologic studies report that 12-25% of all American school-age
children and 13% of preschoolers have an emotional and/or behavioral disorder.3-8
The rates of psychosocial impairment are higher in risk groups such as low
income and/or single parent households.
Pediatricians have long been an important first resource for parents who are worried about their children's behavioral problems.9 With the advent of managed and especially capitated health care systems,10 primary care providers assume an even greater "gatekeeping" responsibility to identify, manage and refer children with emotional and/or behavioral disorders.11 Yet, recent studies estimate that only about 50% of these children are identified by their primary care physicians and that once identified, only a fraction of these children receive appropriate mental health treatment.9, 12-15
A number of studies16-19 have documented an increasing prevalence of behavioral and emotional problems in the U.S. and other countries in children and adults. Despite the growing burden of psychosocial morbidity, pediatricians still do not receive adequate training concerning psychosocial problems,20 are hesitant to attach potentially deleterious labels to children,13 do not have time during office visits to address psychosocial needs, and may have limited access to mental health referral networks.15 Recent efforts such as the American Board of Pediatrics increasing ambulatory and behavioral training requirements, publications such as Bright Futures,21 and the Diagnostic and Statistical Manual for Primary Care22 may help to increase awareness of psychosocial morbidity over the long-term, but as of now primary care pediatricians still struggle to provide psychosocial services.2, 21-22 The move to managed care approaches in medicine and the increasing focus on productivity and profitability has created an additional pressure for pediatric clinicians to limit attention on psychosocial problems.
One way to counterbalance this pressure is to use a parent-completed screening questionnaire as part of routine primary care visits23 to facilitate recognition and referral of psychosocial problems. The Pediatric Symptom Checklist (PSC) was developed for this purpose. The PSC is a one-page questionnaire listing a broad range of children's emotional and behavioral problems that reflects parents' impressions of their children's psychosocial functioning. Cutoff scores for pre-school and school-age children indicating clinical levels of dysfunction have been empirically derived using Receiver Operator Characteristic analyses in studies comparing the performance of the PSC to other validated questionnaires and clinicians' assessments of children's overall functioning.24-25
In a number of validity studies, PSC case classifications agreed with case classifications on the Children's Behavior Checklist (CBCL), clinicians' Global Assessment Scale (CGAS) ratings of impairment, and the presence of psychiatric disorder in a variety of pediatric and subspecialty settings representing diverse socioeconomic backgrounds.26-30 When compared to Children's Global Assessment Scale scores (CGAS) in both middle and lower income samples, the PSC has shown high rates of overall agreement (79%;92%), sensitivity (95%;88%) and specificity (68%;100%).24-27 Studies using the PSC have found prevalence rates of psychosocial impairment in middle class or general settings (~12%) that are quite comparable to national estimates of psychosocial problems.25-30 More recently, efforts to develop specific subscales of the PSC for use in identification of attentional, internalizing (depression/anxiety), and behavior problems31 and to develop both child-32 and teacher-report versions of the PSC are well along.
Previous studies using a variety of measures have consistently shown that the prevalence of psychosocial impairment varies considerably based on a number of sociodemographic risk factors, and research with the PSC has paralleled many of these findings. For example, low socioeconomic status,33 living with a single parent,34 parental mental illness,35-36 family discord ,37 the child's temperamental characteristics, and male sex 37-38 have all been shown to increase the probability of psychosocial dysfunction. Consistent with these findings, studies using the PSC have shown the prevalence of child psychosocial dysfunction to be two to three times higher in children from low income,27,39 single-parent,27 and/or mentally ill parents.28
Some investigators have recommended that the PSC should be considered "basic office equipment" in pediatrics and others have argued that the PSC should become a mandated part of all well-child visits in managed care settings or large programs like Medicaid EPSDT.23,30,40 Several states (e.g., Arizona, Massachusetts) now recommend the PSC or other brief questionnaires for psychosocial screening during EPSDT, and a number of HMO’s (Kaiser of Northern California, Neighborhood Health Plan of Massachusetts) are piloting the use of the PSC as a routine part of well-child visits. The PSC is also being used as a part of annual screenings in a variety of non-health care settings like Ventura County, California Head Start.
Research currently in progress suggests that routine psychosocial screening with the PSC is associated with increased mental health referrals, decreasing child symptom scores, and increased parental satisfaction. Other studies are looking at the costs of screening and possible cost offsets in pediatric medical costs after children are screened and treated.
1. Haggerty RJ, Roghmann KJ, Pless IB (Eds): Child Health and the Community. New York, John Wiley & Sons, 1975.
2. Kelleher KJ, Wolraich ML. Diagnosing psychosocial problems. Pediatrics. 1995;95:899-901.
3. Costello EJ, Edelbrock C, Costello AJ, Dulcan MK, Burns BJ, Brent D. Psychopathology in pediatric primary care: the new hidden morbidity. Pediatrics. 1988;82:415-424.
4. Brandenburg NA, Friedman RM, Silver SE. The epidemiology of childhood psychiatric disorders: Prevalence findings from recent studies. J Am Acad Child Adolesc Psychiatr. 1990;29:76-83.
5. National Institute of Mental Health. National plan for research on child and adolescent mental disorders. Rockville, MD: National Institute of Mental Health, 1990.
6. Costello EJ, Costello AJ, Edelbrock C, Burns BJ, Dulcan MK, Brent D, Janiszewski S. Psychiatric disorders in pediatric primary care: Prevalence and risk factors. Arch Gen Psychiatr. 1988;45:1107-1116.
7. Costello EJ, Angold A, Burns B. et al. The Great Smoky Mountains Study of Youth: Goals, design, methods, and the prevalence of DSM III-R disorders. Arch Gen Psychiatr. 1996:53;1129-1136.
8. Lavigne JV, Binns HJ, Christoffel KK, et al. Behavioral and emotional problems among preschool children in pediatric primary care: Prevalence and pediatricians' recognition. Pediatrics. 1993;91:649-657.
9. Sharp L. Pantell RH, Murphy LO, Lewis CL. Psychosocial problems during child health supervision visits: Eliciting, then what? Pediatrics. 1992;89:619-623.
10. Institute of Medicine. Primary Care: America's Health in a New Era: Part 2: Appendixes. Washington DC, National Academy Press, in press.
11. Jellinek MS. Managed Care: good news or bad news for children? J Dev Behav Pediatr. 1994;15:273-274.
12. Costello EJ, Janiszewski S. Who gets treated? Factors associated with referral in children with psychiatric disorders. Acta Psychiatr Scandinavia. 1990;18:523-529.
13. Costello EJ: Primary care pediatrics and child psychopathology: A review of diagnostic, treatment, and referral practices. Pediatrics. 1986;78:1044-1051.
14. Starfield B: Behavioral pediatrics and primary health care. Pediatr Clinical North America. 1982;29:377-390.
15. Jellinek M. The present status of child psychiatry in pediatrics. N Engl J Med. 1982;306:1227-1230.
16. Cross-National Collaborative Group. The changing rate of major depression: Cross-national comparisons. JAMA. 1992;268:3098-3105.
17. Achenbach TM, Howell CT. Are American children’s problems getting worse?: A 13-year comparison. J. Am. Acad. Child Adolesc. Psychiatry. 1993;32(6):1145-1154.
18. Kelleher KJ, Childs G, Wasserman RC, McInerny T, Nutting P, Gardner, WP. Insurance status and the recognition of psychosocial problems: A report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Networks. Arch. Ped. Adolesc. Medicine. 1998;151:1109-1115
19. Ryan ND, Williamson DE, Iyengar S, Orvaschel H, Reich T, Dahl RE, Puig-Antich J. A secular increase in child and adolescent onset affective disorder. J. Am. Child Adolesc. Psychiatry. 1992;31(4):600-605.
20. Wissow LS, Roter DL, Wilson MEH. Pediatrician interview style and disclosure of psychosocial issues. Pediatrics. 1994;93(2):289-295.
21. Green M. (Ed.) Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. National Center for Education in Maternal and Child Health, 1996.
22. American Academy of Pediatrics. The Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. American Academy of Pediatrics, 1996.
23. Sturner RA. Parent questionnaires: basic office equipment? J Dev Behav Pediatr. 1991;12:51-54.
24. Jellinek MS, Murphy JM, Burns BJ. Brief psychosocial screening in outpatient pediatric practice. J Pediatr. 1986;109:371-378.
25. Little M, Murphy JM, Jellinek MS, Bishop SJ, Arnett HL. Screening four and five-year-old children for psychosocial dysfunction: A preliminary study with the Pediatric Symptom Checklist. J Dev Behav Pediatr. 1994;15:191-197.
26. Jellinek MS, Murphy JM, Robinson J, et al. The Pediatric Symptom Checklist: Screening school-age children for psychosocial dysfunction. J Pediatr. 112;201-209:1988.
27. Murphy JM, Reede J, Jellinek MS, Bishop, S.J. Screening for psychosocial dysfunction in inner-city children: Further validation of the Pediatric Symptom Checklist. J Am Acad Child Adolesc Psychiatr. 1992;31:1105-1111 .
28. Jellinek MS, Bishop SJ, Murphy JM, Biederman J, Rosenbaum JF. Screening for dysfunction in the children of outpatients at a psychopharmacology clinic. Am J Psychiatr. 1991; 148:1031-1036.
29. Rauch PK, Jellinek MS, Murphy JM, Schachner L, Hansen R, Esterly NB, Prendiville J, Bishop SJ, Goshko M. Screening for psychosocial dysfunction in pediatric dermatology practice. Clinical Pediatrics. 1991; 30:493-497.
30. Murphy JM, Ichinose C, Hicks RC, Kingdon D, Crist-Whitzel J, Jordan P, Feldman G, Jellinek MS. Utility of the Pediatric Symptom Checklist as a psychosocial screen in EPSDT. J Pediatrics. 1996;129:864-869.
31. Gardner W, Murphy JM, Childs G, Kelleher K, Pagano M, Jellinek M, McInerny TK, Wasserman RC, Nutting P. The PSC-15: A Brief Pediatric Symptom Checklist with psychosocial problem subscales. A report from PROS and ASPN. Under review.
32. Pagano ME, Cassidy LJ, Murphy JM, Little M, Jellinek MS. Identifying school-age children at risk: The Pediatric Symptom Checklist as a self-report measure. Accepted at Psychology in the Schools, August 1998.
33. Jensen PJ, Bloedau L, Degroot J, Ussery T, Davis H. Children at risk: I. Risk factors and child symptomatology. J Am Acad Child Adolesc Psychiatr. 1990;29:51-59.
34. Rutter M. Epidemiological/longitudinal strategies and causal research in child psychiatry. J Am Acad Child Psychiatr. 1981;20:413-544.
35. Pfeffer CR, Plutchik R, Mizruchi MS. A comparison of psychopathology in child psychiatric inpatients, outpatients, and nonpatients: implications for treatment planning. J Nerv Ment Dis. 1986;174:529-535.
36. Orvaschel H, Weissman MM, Padian N, Lowe TL. Assessing psychopathology in children of psychiatrically disturbed parents. J Am Acad Child Psychiatr. 1981;20:112-122.
37. Earl F, Jung KG. Temperament and home environment characteristics as causal factors in the early development of childhood psychopathology. J Am Acad Child Adolesc Psychiatr. 1987;26:491-498.
38. Kashani JH, Beck NC, Burk JP. Predictors of psychopathology in children of patients with major affective disorders. Can J Psychiatr. 1987;32:287-290.
39. Jellinek MS., Murphy JM, Little M, Pagano ME, Comer D, Kelleher K. The use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: A national feasibility study. Accepted for publication in Arch. Ped. And Adolesc. Med. 1998.
40. Pagano M, Murphy JM, Pederson M, Mosbacher D, et al. Screening for psychosocial problems in four and five year-olds during routine EPSDT examinations; Validity and reliability in a Mexican-American sample. Clinical Pediatr. 1996;35:139-146.