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Use of Child Reports of Daily Functioning to Facilitate Identification of Psychosocial Problems in Children
Beth G. Wildman, PhD;
Anne M. Kinsman, PhD;
William D. Smucker, MD
Arch Fam Med. 2000;9:612-616.
ABSTRACT
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Background Despite the availability of effective screening measures, physicians fail to identify and manage many children with psychosocial problems. Physicians are most likely to identify children with psychosocial problems when parents voice concerns about their child's functioning. However, few parents express concerns to their child's physician, and children's perspectives of their own functioning are rarely considered. This study evaluated the potential utility of children's reports of their own functioning.
Methods The Child Functioning Scale (CFS) was completed by 107 parents and children and compared with the Pediatric Symptom Checklist (PSC) and physician reports on the psychosocial status of each child.
Results Physicians identified 20% of the children identified by the PSC. Children's self-reported problems on the CFS would have identified 53.3% of these children. Additionally, 11.2% of children who did not meet criteria on the PSC self-reported problems in daily functioning.
Conclusion Collecting information about children's perceptions of their own daily functioning could provide physicians with an additional tool for the assessment of psychosocial problems.
INTRODUCTION
EPIDEMIOLOGICAL studies indicate that between 15% and 20% of children experience psychosocial problems (ie, behavioral and emotional problems), yet less than 2% of children are seen by mental health professionals in a given year.1-2 Many children with psychosocial problems are managed exclusively by primary care physicians. However, Costello et al1 reported that physicians identify only 17% of these children, leaving 83% of children with psychosocial problems unidentified.
Children with untreated psychosocial problems are likely to experience difficulties in various aspects of their daily functioning (eg, school and relationships with peers and family) and have problems that are severe and persist over time.3-5 Because of their relatively early and consistent contact with their child patients, primary care physicians often are asked to identify and manage these children. Access to mental health services often requires and is facilitated by a referral from a primary care physician.
Suggestions for improving the rate of identification of children with psychosocial problems have included improved physician communication, prompting parents to disclose more psychosocial information to their child's physician, and paper-and-pencil instruments for screening children with or at risk for psychosocial problems.6-10 However, none of these interventions has significantly affected the problem of underidentification of these children.
Previous research has found that physicians are very likely to identify children as having psychosocial problems when parents disclose concerns about their child's functioning to them.8 However, parents rarely make such disclosures, and research designed to increase these disclosures has not led to substantial increases in the number of parents disclosing relevant psychosocial information.8-9 Another source of information available to physicians is the child. Perhaps the child can provide relevant information about himself or herself that may be useful to physicians and is likely to differ from the information provided by parents.11-14 For example, older children tend to report fewer disruptive behavior problems and more depression and anxiety problems than do their parents.14 Reports from the child could provide information about the child's private feelings.
The purpose of this study was to evaluate whether information provided by the child about daily functioning could help physicians identify children with psychosocial problems, and whether the information provided by children has the potential to supplement the information that mothers provide.
PARTICIPANTS AND METHODS
PARTICIPANTS
Participants were 166 mothers and their children, aged 5 to 12 years, presenting for primary medical care for the child at 3 community-based family medical practices. All children were currently attending elementary school or would enter elementary school during the next school year. Undergraduate research assistants were assigned 3-hour shifts at 1 of 3 family practices on a rotating basis for approximately 1 year. They approached 291 mothers, of whom 166 agreed to participate and provide completed questionnaires. The 8 physicians from the 3 family medical practices provided information about 107 of the children. Physician data are lacking for the remaining 59 children for a variety of reasons, including physicians neglecting to complete the form and improper coding of the participant identification number on the physician form.
MEASURES
Pediatric Symptom Checklist
The Pediatric Symptom Checklist (PSC)10 is a well-standardized 35-item parent-completed questionnaire that was designed for use in pediatric outpatient settings to assess the psychological functioning of school-aged children.15 Elevated scores on the PSC indicate the need for further psychological assessment.15 Jellenik et al10, 15 reported adequate test-retest reliability and internal consistency, with a specificity of 0.68 and sensitivity of 0.95 for the PSC with clinician ratings.10, 15 As suggested by Jellenik et al,10 a score greater than or equal to 28 was used in our study to indicate clinically significant child psychosocial problems.
Child Functioning Scale
The Child Functioning Scale (CFS)16 is a screening instrument of child functioning in important areas of daily life. The CFS assesses the daily functioning of children in the domains of peer interactions, school, parent and child relationships, sibling relationships, health, and overall self-perception. Both parents and children complete this measure using a 3-point scale that has the choices of "great," "sort of OK," or "not good." The child's version is administered orally and pictures are provided to facilitate responding (Figure 1). Two questions using the 3 response alternatives and pictures are administered prior to the measure to familiarize children with the task. The low-mean interitem correlation of 0.14 on the CFS-C (child-completed CFS) with a minimum correlation of -0.08 and a maximum correlation of 0.36 indicates that, as expected, children responded differently to questions about different areas of functioning. The higher mean interitem correlation of 0.30 with a minimum correlation of 0.05 and a maximum correlation of 0.58 on the CFS-P (parent-completed CFS) indicates that mothers did not differentiate in their reports of their children's functioning in the 6 areas assessed as well as their children did. As suggested by Kinsman,16 a score greater than or equal to 10 was used to indicate overall psychosocial distress.
Family Demographics Questionnaire
The Family Demographics Questionnaire contained demographic questions about the family, such as the child's race, type of medical insurance, parental education, and marital status of parents.
Physician Checklist
The Physician Checklist was based on categories developed by the World Health Organization, and was adapted from previous research done in primary care settings.17-18 The Physician Checklist was used to assess physician identification of child behavior problems. The question that was used to indicate physician identification of a psychosocial problem in the current study was, "Are you concerned the child might have any type of psychosocial or developmental problem?" The Physician Checklist required approximately 1 minute to complete.
PROCEDURES
Undergraduate research assistants used a standard protocol approved by the Kent State University, Kent, Ohio, Human Subjects Review Board to recruit mothers visiting the physician with their children. Mothers were provided with verbal and written descriptions of the study and written consent was obtained. Verbal assent was obtained from the child. As part of a larger study, mothers completed the PSC, CFS-P, and Family Demographics Questionnaire in the waiting room. The CFS-C was administered verbally to the child by a research assistant without the parent immediately present, in a part of the waiting room out of hearing range of the mother.
RESULTS
DEMOGRAPHIC DATA
Ages of the 166 children ranged from 5 to 12 years with a mean age of 7.6 years. The sample was composed of 51.8% boys and 48.2% girls. The sample was primarily white (97.6%). The remaining participants were 1.2% African American and 1.2% did not indicate their race. Insurance and parent educational attainment were used as indicators of socioeconomic status. Private insurance was used by 89.8% of the sample, 4.8% used Medicaid, and 3% had no medical insurance. The median education level of the mothers was completion of some college courses without obtaining a degree. The majority of mothers (89.3%) were currently married. Ages of the mothers ranged from 24 to 53 years, with a mean age of 36.8 years. The subsample of 107 children for whom Physician Checklists were available closely matched the larger sample for all demographic categories.
PSYCHOSOCIAL STATUS OF THE CHILDREN
Scores on the PSC indicated that 28 children (16.9%) in the sample had scores indicative of clinically significant psychosocial problems. Responses on both the CFS-C and CFS-P indicated that 33 children (19.9%) were experiencing dysfunction overall. A total of 56 children had elevated scores on either the CFS-C or the CFS-P. Parents and children agreed that 12 of these children (21.4%) were experiencing dysfunction.
RELATIONSHIPS BETWEEN CHILD- AND PARENT-REPORTED FUNCTIONAL STATUS
Analysis of the CFS-C and CFS-P indicated that, as expected, there was low agreement between parents and children about the presence of problematic daily functioning ( =0.18 [N=164]:  21=5.55, P<.05).19 Finding a lack of agreement between parental reports and child self-reports has been well-documented and supports the importance of obtaining information directly from the child.11-13,20
DIFFERENCES BETWEEN REPORTS OF MOTHERS AND CHILDREN AND RELATIONSHIP TO PSC
The usefulness of child report was investigated by determining how much child reports could have improved identification of psychosocial problems in children when the PSC was used as the criterion for the presence of psychosocial problems. Physicians identified 6 children, 5.6% of the sample, as having psychosocial problems. Table 1 presents the relationship among the CFS-P, CFS-C, and physician report. The CFS-P identified 17 children (15.9%) as having psychosocial problems. The physicians identified 4 of these children (23.5%) as having psychosocial problems. When children reported on their own functioning using the CFS-C, 20 (18.7%) had scores indicative of psychosocial problems. The physicians identified 3 of these children (15%) with psychosocial problems.
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Table 1. Agreement Among Physician Checklist and the Child Functioning Scale, Parent-Completed and Child-Completed (N=107)*
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The potential value of obtaining child reports was investigated by determining the number of children identified by the CFS-C but not by physicians when the PSC was used as the criterion for presence of psychosocial problems. Table 2 presents the relationship between the PSC and the CFS-C. Based on the PSC, 15 children (14%) had scores above the cutoff for psychosocial problems. The physicians identified 3 of these children (20%) with psychosocial problems. Physicians failed to identify 12 (80%) of the 15 children identified with psychosocial problems by the PSC. Comparison of the CFS-C and physician identification rate indicated that use of child reports could have improved physician identification rate when the PSC was used as the criterion for presence of psychosocial problems. Neither the physicians nor the CFS-C identified 5 children (33.3%) who were classified with psychosocial problems by the PSC. Physicians identified 2 of the children (13.3%) identified by the PSC, but not by the CFS-C. The CFS-C identified 8 of the children (53.3%) who were identified by the PSC. Of these 8 children, the physicians identified only 1 (12.5%). Additionally, 12 children (11.2%) self-reported problems in their daily functioning, but did not meet the criterion for a psychosocial problem on the PSC. The physicians identified 3 of these 12 children as having a psychosocial problem.
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Table 2. Agreement Between Pediatric Symptom Checklist and the Child-Completed Child Functioning Scale (CFS-C) (N=107)
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COMMENT
The results of the present study support the utility of asking children about their own daily functioning. The findings suggest that children self-report information that is different from the information provided by their mothers. In addition, the information provided by children would have increased the number of children with psychosocial problems identified by the physicians.
The discrepancies between mother and child reports are likely to be due to either children reporting on internal states and feelings that are not accessible to the mother or the use of different evaluation criteria. These discrepancies are consistent with previous research reporting poor agreement between parents', teachers', and children's reports of child behavior.11, 13, 21 Kinsman16 reported that mothers evaluated children globally, whereas children discriminated in their reports on the different aspects of daily functioning that were assessed. Use of the child's perspective has the potential to aid physicians in identifying children at risk for psychosocial problems.
Several limitations must be considered when interpreting the results of the present study. It used a new, nonstandardized measure of child functional status; however, reliability and validity data suggest its appropriateness for the current research.16 In addition, the questions on the CFS are similar to questions that physicians routinely ask parents. Participants in this study were relatively homogeneous in socioeconomic status, as determined by type of medical insurance and level of education. In addition, all physicians in the study had completed residency training and had been in practice in the community for many years.
A final limitation was the reliance on only paper-and-pencil measures and primarily maternal report. As discussed earlier, parental report is often influenced by psychological and familial functioning, resulting in attenuated concordance between informants and overestimations or underestimations of the presence or absence and severity of child psychosocial problems.12, 22 Use of other methods of assessment (eg, interviews and observations) may have provided additional information concerning the accuracy and concordance between parent and child reports.
The use of child self-reports of daily functioning in screening for child psychosocial problems offers a potentially valuable supplement to parent reports of child psychosocial status in the context of routine medical care. Children seem to provide unique information compared with their mothers. Obtaining easily accessible information from both the parent and the child may be valuable for primary care physicians who must often identify those children and families in need of further evaluation and/or treatment for psychosocial problems in the context of a brief office visit. The results of the present research reinforce the need for primary care physicians to routinely incorporate screening procedures for psychosocial problems into their practices.
AUTHOR INFORMATION
Accepted for publication October 22, 1999.
Corresponding author: Beth G. Wildman, PhD, Department of Psychology, Kent State University, Kent, OH 44242 (e-mail: bwildman{at}kent.edu).
From the Department of Psychology, Kent State University, Kent, Ohio (Drs Wildman and Kinsman); and the Department of Family Medicine, Northeastern Ohio Universities College of Medicine, Rootstown (Dr Smucker). Dr Kinsman is now with the Cincinnati Center for Developmental Disorders at Children's Hospital Medical Center, Cincinnati, Ohio.
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