Pediatric Symptom Checklist: A primary care screening tool to identify psychosocial problems

Description

The authors describe their practice-friendly tool for identifying problems in primary care.

Learning objectives

Mental health referral and office based interventions

Know indications for mental health referral during the course of primary care intervention for behavior problems.

Know specific screening instruments

Be aware of specific screening instruments with appropriate sensitivity, specificity, and ease of use in primary care.

Know how to use the Pediatric Symptom Checklist

Know how to use the Pediatric Symptom Checklist to identify behavioral and mental health problems in primary care practice.

Introduction

Pediatricians have long been an important first resource for parents who are worried about their children's behavioral problems. Primary care providers in managed care settings assume an even greater "gatekeeping" responsibility to identify, manage and refer children with emotional and/or behavioral disorders. 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.

12-25% of all American school-age children and 13% of preschoolers have an emotional and/or behavioral disorder. The rates of psychosocial impairment are higher in risk groups such as low income and/or single parent households. A number of studies 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 often may not receive adequate training concerning psychosocial problems, are hesitant to attach potentially deleterious labels to children, do not have time during office visits to address psychosocial needs, and may have limited access to mental health referral networks.

There has been increasing attention on psychosocial problems. Organized medical education groups have increased the behavioral training requirements. Publications such as Bright Futures, and the Diagnostic and Statistical Manual for Primary Care 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.

Managed care and the increasing focus on productivity and profitability are creating additional pressure for pediatric clinicians to limit attention on psychosocial problems. One way to counterbalance these pressures is to use a parent-completed screening questionnaire as part of routine primary care visits which would facilitate recognition of psychosocial problems. The Pediatric Symptom Checklist (PSC) was developed to serve this purpose.

What is the PSC?

The PSC is a one-page questionnaire listing a broad range of children's emotional and behavioral concerns that reflects parents' impressions of their children's psychosocial functioning. In a number of validity studies, PSC case classifications agreed with case classifications on the Child Behavior Checklist (CBCL), Clinicians' Global Assessment Scale (CGAS) ratings of impairment, and the presence of a psychiatric disorder in a variety of pediatric and subspecialty settings representing diverse socioeconomic backgrounds.

Compared with the CGAS, the PSC has 79% agreement for middle income children and 92% agreement for lower income children. Sensitivity is 95% for middle income and 88% for lower income and specificity 68% for middle income and 100% for lower income children.

Studies using the PSC have found prevalence rates of psychosocial impairment in middle class or general settings of about 12%, quite comparable to national estimates of psychosocial problems. 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.

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.

Use in Practice

The PSC is designed to be administered in the waiting room and scored by a receptionist or clinical aide. A positive score reflects a high likelihood that a child is having significant psychosocial dysfunction. Although certain responses may suggest a diagnosis, the PSC is a screening tool and not diagnostic. If positive, the clinician should pursue a brief interview reviewing the child's major areas of functioning (school, family, activities, friends and mood). If this brief interview supports the PSC findings, the clinician then decides whether a follow-up appointment, further evaluation or referral is indicated.

Administration and Scoring

The Pediatric Symptom Checklist obtains parents' reports of children's behavioral/emotional problems on 35 items that describe specific behaviors and emotions. Parents rate their child for how true each item is using the following scale: 0= not true (as far as you know); 1=somewhat or sometimes true; 2=very true or often true. For school aged children 6-16 years, a total score of 28 or higher is taken as an indication of significant and psychosocial impairment. For children ages 2-5, the scores on items 6, 7, 17 and 18 are ignored and a total score based on the 31 remaining items is completed.

The cutoff score for younger children is 24 or greater. Although parents have been shown to be the most reliable reporters of their children's psychosocial and behavioral problems, some mood disorders especially in adolescents are more reliably identified by the patients themselves. When problems like these are suspected interviewing the child or adolescent, the youth self-report of the PSC, or a specific disorder screen like the Children's Depression Inventory may be more valid.

Future Directions

Parental acceptance of the PSC has been reconfirmed by our recent research on a national sample. Poverty, single parent family, family history of mental illness, among other factors, elevates the percentage of children scoring positive on the PSC. We are now studying whether recognizing problems using the PSC will reduce costs by decreasing the utilization of primary health care.

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