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

doi:10.1016/j.acap.2009.03.004

Academic Pediatrics

Volume 9, Issue 4, July–August 2009, Pages 270-277

https://doi.org/10.1016/j.acap.2009.03.004 Get rights and content

Objective

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.

Methods

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.

Results

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.

Conclusions

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.

Section snippets

Setting

The study setting was 2 outpatient pediatric clinics of the Cambridge Health Alliance, a public hospital system serving the ethnically and racially diverse cities of Cambridge, Somerville, Everett, Malden, Chelsea, and Revere.

Cambridge and Somerville Pediatrics care for more than 10 000 patients (36% under age 5) and serve diverse multicultural and immigrant populations, with large percentages covered by public payers including Medicaid and the Uncompensated Care Pool (Free Care).²² PSC

Results

Of the 3023 eligible patients seen at the clinics during the study period, 2129 received the PSC/Y-PSC (70.4%) at their first visit. Of these patients, 1479 (69.5%) returned for a preventive visit within the next 10 to 18 months, and 1035 were screened at their second preventive visit (a screening rate of 70.0%). Pediatricians and administrators cited reasons for lack of screening as no screen provided by the front desk, literacy problems, lost forms, and language barriers. Two screened

Discussion

Our study represents the first examination of the stability and change in PSC scores over time in a naturalistic pediatric setting. The findings demonstrate the stability of scores for patients who originally screened negative and the course of change for those who originally screened positive on the PSC in a diverse sample of approximately 1000 children. Similar percentages of the population were identified by the measure at both visits, and PSC scores were highly stable for those who scored

Acknowledgments

Supported in part by a grant through the Healthy Tomorrows Partnership for Children Program, a public private partnership between the Maternal and Child Health Bureau, the Health Resources and Services Administration, and the American Academy of Pediatrics (grant H57MC07372; PI, Karen A. Hacker, MD).

None of the authors has any financial interests in the subject contained in this article. Dr Murphy is one of the developers of the Pediatric Symptom Checklist, which is free to users.

We thank the

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Among Latinx youth, migration trauma, acculturative stress, and discrimination is associated with lower levels of self-esteem and higher levels of depressive symptoms, anxiety, post-traumatic stress disorder, attention-deficit/hyperactivity disorder and conduct disorder.38,39 Among immigrants, limited English proficiency and literacy limitations have also proven to be barriers in behavioral health screening among children.38,40 The intersectionality of discrimination within behavioral health care is compounded with the experience of being overlooked in daily life, which makes it more difficult for people of color to seek help for deeper issues.41
A pilot randomized trial teaching mindfulness-based stress reduction to traumatized youth in foster care
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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.
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Alternatively, it is possible that the self-assessment screening process along with provider discussion and referral may have some therapeutic benefits [36]. In a prior study [19], the authors found that the only factor predicting a decrease in PSC score was a referral regardless of treatment. Unfortunately, in this study, few PCPs indicated what their “discussion” with patients entailed.
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.
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.
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.
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.
Universal mental health screening in pediatric primary care: A systematic review
2013, Journal of the American Academy of Child and Adolescent Psychiatry
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In a survey of parents of children with mental health problems, screening was seen by the parents as an opportunity for doctors to signal that mental health problems beyond common concerns such as attention-deficit/hyperactivity disorder (ADHD) were appropriate for discussion in primary care.38 Only 6 studies stated or implied that providers were taught how to score the screens used,8,11,12,39,47,49 and only 1 stated explicitly that providers were taught that a screen could have variable and low predictive values depending on the cut-point used.8 In 20 studies, screens were scored by a computer, research assistant, or co-located mental health provider.10,34,40,43-45,48,50,51,56-59,64,65,70-72,75
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.
Mental and behavioral health screening at preventive visits: Opportunities for follow-up of patients who are nonadherent with the next preventive visit
2011, Journal of Pediatrics
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.
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2009, Academic Pediatrics
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However, although most pediatricians feel responsible for identifying child behavior and mental health problems,15 most do not feel responsible for routinely identifying maternal mental health problems.16 Looking at persistence and change in Pediatric Symptom Checklist scores in a pediatric primary care setting, Hacker and her colleagues1 found that many with positive screens did not return for follow-up, and only 26% of those referred for services completed at least 1 visit to a mental health provider. This result is consistent with the 2000 Report of the National Institutes of Health,17 which indicated that only 20% to 25% of children with emotional problems receive treatment.

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Mental Health and Child DevelopmentPersistence and Change in Pediatric Symptom Checklist Scores Over 10 to 18 Months

Objective

Methods

Results

Conclusions

Section snippets

Setting

Results

Discussion

Acknowledgments

J Am Acad Child Adolesc Psychiatry

Ambul Pediar

J Pediatr

J Pediatr

J Am Adac Child Adolesc Psychiatry

Mental Health: A Report of the Surgeon General

Suicide and suicide attempts in adolescents

Pediatrics

Identification and management of psychosocial problems by preventive child health care

Arch Pediatr Adolesc Med

Screening for psychosocial dysfunction in pediatric practice. A naturalistic study of the Pediatric Symptom Checklist

Clin Pediatr

A review of behavioral screening practices in pediatric settings: do they past the test?

J Dev Behav Pediatr

Screening for mental health in pediatric practice: factors related to positive screens and the contribution of parental/personal concern

Pediatrics

Prevalence and development of psychiatric disorders in childhood and adolescence

Arch Gen Psychiatry

Change in children's emotional and behavioral problems over a one-year period

Eur Child Adolesc Psychiatry

Mental health problems of children in the community: 18 month follow up

BMJ

Mental Health and Child Development
Persistence and Change in Pediatric Symptom Checklist Scores Over 10 to 18 Months