Identification of psychosocial problems in pediatric primary care: do family attitudes make a difference?

Increasing the psychosocial focus in child developmental assessments: a qualitative study

BACKGROUND

Previous studies have indicated a need for increased psychosocial focus on children and their families to improve children's wellbeing and mental health. Child developmental assessments could be a place to implement changes to achieve this. A standardised record might be helpful to clinicians trying to increase psychosocial focus. The aim of this study is to investigate clinical barriers and facilitators when introducing standardised child records with increased focus on psychosocial wellbeing and mental health into child developmental assessments.

METHODS

This is a qualitative study based on 12 semi-structured interviews with four midwives and nine doctors who carry out child developmental assessments in general practice. Data is analysed in the framework of Normalisation Process Theory.

RESULTS

General practice-based clinicians were positive towards increasing the psychosocial focus in child developmental assessments. The main barriers when clinicians used the standardised child records were: feeling forced to ask certain questions, in turn making the conversation rigid; leaving less room for parents to bring up other issues; making clinicians feel awkward when addressing problems that they cannot solve; the need for extended consultation time; and medico-legal concerns when registering findings. The experience of positive aspects when using the standardised child records facilitated continuous use of the records. Positive aspects included having a standardised approach to recording important findings, thereby uncovering psychosocial problems that could potentially be overlooked. Additionally, structured observation of parent-child interaction and gaining a new vocabulary to describe the findings were valued by clinicians. Balancing a standardised approach with clinicians' ability to steer the consultation and explore topics in depth while preserving the potential for patients to bring up other issues became an important theme.

CONCLUSION

Clinicians need to be well-equipped to handle psychosocial problems through coping strategies, referral options and communication techniques in the psychosocial domain. The parent-child-interaction assessment might expose potentially dysfunctional parenting behaviours and could improve communication between health professionals. Implementing standardised child development records with an increased psychosocial focus is feasible but improvements could optimise the use of the records. Parental views on an increased psychosocial focus during child developmental assessments should be investigated prior to further implementation.

TRIAL REGISTRATION

Trial registry number for the FamilieTrivsel (Family Wellbeing) trial: NCT04129359.

Enhancing the primary care pediatrician's role in managing psychosocial issues: a cross sectional study of pediatricians and parents in Israel

Background

Psychosocial issues are an integral part of children's health and well-being, and it is widely acknowledged that pediatricians should be involved in their management. We examined the current perception of the pediatrician’s role in the management of psychosocial problems in Israel from the perspective of parents and pediatricians, and identified possible barriers.

Methods

We assessed parents' and pediatricians' perspectives through a cross sectional survey. 1000 parents with children under 10 were randomly selected from a large database representing the Israeli population and phone-surveyed by a polling company. Due to a low response-rate (5.4%), there was an overrepresentation of married parents and underrepresentation of parents with primary or secondary education. 173 Pediatricians were recruited both at a medical conference and by a web-based questionnaire.

Results

55% of the parents reported they were concerned with at least one psychosocial problem, yet less than 50% of them discussed these issues with the pediatrician. 59.9% of the parents did not perceive psychosocial problems as relevant to the pediatrician's role. Pediatricians with some previous training related to psychosocial issues were more likely to report on a lack of professional confidence (p = .037) and insufficient available resources (p = .022) as barriers to their involvement, while pediatricians who had no training were more likely to report on the parents' perception of their role as the barrier to involvement (p = .035).

Conclusions

Parents tend to avoid the discussion of psychosocial concerns in pediatric settings due to their perception that it's irrelevant to the pediatrician's role. Trained pediatricians feel unconfident in their ability to manage psychosocial issues and report on a lack of suitable resources. These findings suggest current pediatric mental-health training is insufficient to equip pediatricians with the knowledge and skills required to their involvement in psychosocial problems, and imply necessary changes to environment of community-based pediatrics. In order to change the practice of pediatricians in the community to enable them to address a variety of psychological issues, appropriate training is needed, through all stages of the pediatrician’s professional life, including medical school, pediatric residency and continuous medical education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-022-00537-6.

Family History of Mental Health Disorders and Parental Help-Seeking for Behavioral Health Concerns in Pediatric Primary Care Offices

INTRODUCTION

Pediatric mental health needs are common in primary care, but many children never access treatment. With parents as a critical gatekeeper, it is important to identify barriers and facilitators to treatment access and explore the role of family history.

METHOD

Parents/caregivers (N = 1,763) with children aged 3-17 years were recruited in the original study and participated in a 71-item survey that addressed mental health-related communication.

RESULTS

An association was found between family history of mental health disorders and recognition of behavioral concerns, and between anxiety/depression disorders and sharing of concerns. In addition, parents with a family history were less likely to feel completely satisfied with time spent discussing mental health or with how the provider answered questions.

DISCUSSION

Although fear of stigma has been previously cited in the literature as a barrier to accessing treatment, findings suggest a family history of mental health disorders can facilitate parental help-seeking steps.

Awareness screening and referral patterns among pediatricians in the United States related to early clinical features of spinal muscular atrophy (SMA)

Background

Spinal Muscular Atrophy (SMA), a leading genetic cause of death in infants, is an autosomal recessive neuromuscular disease characterized by progressive muscle weakness and atrophy. While early diagnosis of SMA is critical to modifying disease progression and improving outcomes, serious diagnostic delays persist. There is a need to improve SMA awareness, screening, and referral patterns.

Methods

Two online surveys, developed by Cure SMA for general pediatricians, were distributed by Medscape Education via email (September 2018, n = 300, December 2019, n = 600). The surveys asked about adherence to the American Academy of Pediatrics (AAP) developmental screening and surveillance guidelines, comfort with identification of early signs of neuromuscular disease (NMD), familiarity with SMA, and barriers to timely referral.

Results

In 2018, 70.3% of survey respondents indicated comfort in identifying early signs of NMD and 67.3% noted familiarity with SMA. 52.7% correctly indicated the need for genetic testing to make a definitive diagnosis of SMA, 74.0% meet or exceed developmental screening recommendations, and 52.0% said they would immediately refer to a specialist. In 2019, with a larger sample, 73.0% adhere to developmental screening guidelines, and awareness of the genetic testing requirement for SMA was significantly lower by 7.7% (p < 0.03). Specialist wait times emerged as a barrier to referral, with 64.2% of respondents citing wait times of 1–6 months.

Conclusions

Many pediatricians underutilize developmental screening tools and lack familiarity with diagnostic requirements for SMA. Continuing efforts to expand awareness and remove barriers to timely referral to SMA specialists, including reducing appointment wait times, are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02692-2.

Dealing with parental concerns: A study of GPs' practice

OBJECTIVE

To investigate patterns of GPs' exploration and termination of dialogues about parental concerns in preventive child health assessments.

METHODS

Interactional microanalysis of video recordings of 32 preventive child health assessments using conversation analysis.

RESULTS

The GPs asked parents about concerns, but most concerns disclosed by parents were still left unexplored at the end of the consultation. Termination of dialogues about concerns could be achieved effectively by GPs through letting the biomedical agenda dominate or addressing the child directly. The parents generally cooperated with the various approaches to handling concerns.

CONCLUSION

GPs displayed initial attentiveness towards emotional concerns but did not always follow through with subsequent exploration; many concerns raised were left unexplored. However, the same GP could employ both non-exploratory and exploratory practice within individual consultations.

PRACTICE IMPLICATIONS

Preventive child heath assessments offer an opportunity for parents to raise concerns about their children's development. Improved understanding of the conversational mechanisms through which concerns are examined or sidelined could allow clinicians to maximise the effectiveness of their preventive consultations.

Factors associated with the identification of child mental health problems in primary care-a systematic review

Background: Although common and often with long-lasting effects, child mental health problems (MHPs) are still under-recognized and under-treated. A better understanding of the factors associated with the identification of MHPs in primary care may improve the recognition of MHPs.

Objectives: To review studies on factors associated with the identification of child MHPs in primary care.

Methods: Six leading databases were systematically searched until 1 October 2018. Two independent researchers selected articles and extracted data on study characteristics and factors associated with MHP identification. Inclusion criteria were the investigation of factors associated with MHP identification by primary care professionals (PCPs) in children aged 0–18 years.

Results: Of the 6215 articles identified, 26 were included. Prevalence rates of PCP-identified MHPs varied between 7 and 30%. PCPs identified 26–60% of children with an increased risk of MHPs as indicated by MHP assessment tools, but associated factors were investigated in relatively few studies. MHPs were more often identified in children with a family composition other than married parents, with worse mental health symptoms, prior MHPs, among boys in elementary school, when contact with PCPs was related to parental psychosocial concerns or routine health check-ups, when PCPs were recently trained in MHPs or when PCPs felt less burdened treating MHPs.

Conclusion: MHP identification varied substantially between studies and PCPs and was related to several child, family and practice factors. Future studies should systematically investigate factors associated with MHP identification by PCPs and specifically in children with an increased risk of MHPs according to mental health assessment tools.

Psychosocial Screening in Disorders/Differences of Sex Development: Psychometric Evaluation of the Psychosocial Assessment Tool

BACKGROUND/AIMS

Utilization of a psychosocial screener to identify families affected by a disorder/difference of sex development (DSD) and at risk for adjustment challenges may facilitate efficient use of team resources to optimize care. The Psychosocial Assessment Tool (PAT) has been used in other pediatric conditions. The current study explored the reliability and validity of the PAT (modified for use within the DSD population; PAT-DSD).

METHODS

Participants were 197 families enrolled in the DSD-Translational Research Network (DSD-TRN) who completed a PAT-DSD during a DSD clinic visit. Psychosocial data were extracted from the DSD-TRN clinical registry. Internal reliability of the PAT-DSD was tested using the Kuder-Richardson-20 coefficient. Validity was examined by exploring the correlation of the PAT-DSD with other measures of caregiver distress and child emotional-behavioral functioning.

RESULTS

One-third of families demonstrated psychosocial risk (27.9% "Targeted" and 6.1% "Clinical" level of risk). Internal reliability of the PAT-DSD Total score was high (α = 0.86); 4 of 8 subscales met acceptable internal reliability. A priori predicted relationships between the PAT-DSD and other psychosocial measures were supported. The PAT-DSD Total score related to measures of caregiver distress (r = 0.40, p < 0.001) and to both caregiver-reported and patient self-reported behavioral problems (r = 0.61, p < 0.00; r = 0.37, p < 0.05).

CONCLUSIONS

This study provides evidence for the reliability and validity of the PAT-DSD. Given variability in the internal reliability across subscales, this measure is best used to screen for overall family risk, rather than to assess specific psychosocial concerns.

Parental Action and Referral Patterns in Spatial Clusters of Childhood Autism Spectrum Disorder

Sociodemographic factors have long been associated with disparities in autism spectrum disorder (ASD) diagnosis. Studies that identified spatial clustering of cases have suggested the importance of information about ASD moving through social networks of parents. Yet there is no direct evidence of this mechanism. This study explores the help-seeking behaviors and referral pathways of parents of diagnosed children in Costa Rica, one of two countries in which spatial clusters of cases have been identified. We interviewed the parents of 54 diagnosed children and focused on social network connections that influenced parents' help seeking and referral pathways that led to assessment. Spatial clusters of cases appear to be a result of seeking private rather than public care, and private clinics are more likely to refer cases to the diagnosing hospital. The referring clinic rather than information spread appears to explain the disparities.

Communication skills in pediatrics - the relationship between pediatrician and child

Interpersonal and communication skills are 2 essential qualities of every physician. These are separate and distinct parts of the professional character of every physician. In pediatrics these abilities present even a higher impact.We performed a survey-type prospective study based on questionnaires on 100 subjects, equally divided into 4 groups: 25 children, 25 pediatricians, 25 care-givers (parents, tutors, and relatives), and 25 health care staff, in a Tertiary Pediatric Clinic from Romania, between January 2017 and April 2017.We included 100 participants in our study, equally divided into 4 groups: pediatric patients, pediatricians, care-givers, and health care staff. The 1st group comprised 25 children diagnosed with different chronic conditions, presenting the age between 5 and 14 years. The male gender predominated among the children (57%). The lowest general average score for "Communication" section was encountered among pediatricians group, 3.8, while the other 3 groups presented the same average score for this section, that is, 4.6. The children and the health care staff offered the same average score for "Transparency," that is, 4.6, while the pediatricians offered a score of 4.5, and the care-givers of 4.7. The lowest average score for the item "Hospital environment" was given by the doctors, that is, 3.3, followed by care-givers with a score of 3.6, health care staff 3.7, and children with an average score of 3.8. All the 4 groups included in the study offered a general average of 4.9 out of 5 for the "Intercultural issues" section. The lowest average score for "Time management" section was offered by both children and pediatricians, that is, 4.1, while care-givers and health care staff had a slightly better perception regarding this item, offering 4.2 and 4.3, respectively.The opinion among the 4 groups included in the study was generally similar regarding the 5 items assessed by our questionnaires. Therefore, the main aspects that need to be improved in the health care system in downward order are the following: hospital environment, time management, communication, transparency, and intercultural issues.

Addressing Early Childhood Emotional and Behavioral Problems

More than 10% of young children experience clinically significant mental health problems, with rates of impairment and persistence comparable to those seen in older children. For many of these clinical disorders, effective treatments supported by rigorous data are available. On the other hand, rigorous support for psychopharmacologic interventions is limited to 2 large randomized controlled trials. Access to psychotherapeutic interventions is limited. The pediatrician has a critical role as the leader of the medical home to promote well-being that includes emotional, behavioral, and relationship health. To be effective in this role, pediatricians promote the use of safe and effective treatments and recognize the limitations of psychopharmacologic interventions. This technical report reviews the data supporting treatments for young children with emotional, behavioral, and relationship problems and supports the policy statement of the same name.

Integrating Children's Mental Health into Primary Care

Children's mental health problems are among global health advocates' highest priorities. Nearly three-quarters of adult disorders have their onset or origins during childhood, becoming progressively harder to treat over time. Integrating mental health with primary care and other more widely available health services has the potential to increase treatment access during childhood, but requires re-design of currently-available evidence-based practices to fit the context of primary care and place a greater emphasis on promoting positive mental health. While some of this re-design has yet to be accomplished, several components are currently well-defined and show promise of effectiveness and practicality.

The School Children Mental Health in Europe (SCMHE) Project: Design and First Results

Background : The School Children Mental Health in Europe (SCMHE) project aims to build up a set of indicators to collect and monitor children's mental health in an efficient and comparable methodology across the EU countries. It concerns primary schools children aged 6 to 11 years a range where few data are available whereas school interventions are promising. Methods : Three informants were used: parents, teachers and children. In selecting instruments language, instruments were selected according to the easiness to translate them: SDQ (Strengths and Difficulties Questionnaire) for parents and teachers and DI (Dominic Interactive). A two-step procedure was used: schools randomization then six children by class in each grade. Results : 9084 children from seven countries (Italy, Netherlands, Germany, Romania, Bulgaria, Lithuania, and Turkey) completed the Dominic Interactive in their own language. 6563 teachers and 6031 parents completed their questionnaire, and a total of 5574 interviews have been completed by the 3 informants. The participation rate of the children with parents in the participating schools was about 66.4%. As expected teachers report more externalised problems and less internalised problems than parents. Children report more internalised problems than parents and teachers. Boys have consistently more externalised problems than girls and this is the reverse for internalised problems. Combining the diverse informants and impairment levels children with problems requiring some sort of mental health care were about 9.9%: 76% did not see any mental health professional: 78.7% In Eastern countries 63.1% in Western Europe.

Collaboratively reframing mental health for integration of HIV care in Ethiopia

BACKGROUND

Integrating mental health with general medical care can increase access to mental health services, but requires helping generalists acquire a range of unfamiliar knowledge and master potentially complex diagnostic and treatment processes.

METHOD

We describe a model for integrating complex specialty care with generalist/primary care, using as an illustration the integration of mental health into hospital-based HIV treatment services in Ethiopia. Generalists and specialists collaboratively developed mental health treatments to fit the knowledge, skills and resources of the generalists. The model recognizes commonalities between mental health and general medical care, focusing on practical interventions acceptable to patients. It was developed through a process of literature review, interviews, observing clinical practice, pilot trainings and expert consultation. Preliminary evaluation results were obtained by debriefing generalist trainees after their return to their clinical sites.

RESULTS

In planning interviews, generalists reported discomfort making mental health diagnoses but recognition of symptom groups including low mood, anxiety, thought problems, poor child behaviour, seizures and substance use. Diagnostic and treatment algorithms were developed for these groups and tailored to the setting by including possible medical causes and burdens of living with HIV. First-line treatment included modalities familiar to generalists: empathetic patient-provider interactions, psychoeducation, cognitive reframing, referral to community supports and elements of symptom-specific evidence-informed counselling. Training introduced basic skills, with evolving expertise supported by job aides and ongoing support from mental health nurses cross-trained in HIV testing. Feedback from trainees suggested the programme fit well with generalists' settings and clinical goals.

CONCLUSIONS

An integration model based on collaboratively developing processes that fit the generalist setting shows promise as a method for incorporating complex, multi-faceted interventions into general medical settings. Formal evaluations will be needed to compare the quality of care provided with more traditional approaches and to determine the resources required to sustain quality over time.

Services for adolescents with psychiatric disorders: 12-month data from the National Comorbidity Survey-Adolescent

OBJECTIVE

This study examined 12-month rates of service use for mental, emotional, and behavioral disorders among adolescents.

METHODS

Data were from the National Comorbidity Survey Adolescent Supplement (NCS-A), a survey of DSM-IV mental, emotional, and behavioral disorders and service use.

RESULTS

In the past 12 months, 45.0% of adolescents with psychiatric disorders received some form of service. The most likely were those with ADHD (73.8%), conduct disorder (73.4%), or oppositional defiant disorder (71.0%). Least likely were those with specific phobias (40.7%) and any anxiety disorder (41.4%). Among those with any disorder, services were more likely to be received in a school setting (23.6%) or in a specialty mental health setting (22.8%) than in a general medical setting (10.1%). Youths with any disorder also received services in juvenile justice settings (4.5%), complementary and alternative medicine (5.3%), and human services settings (7.9%). Although general medical providers treated a larger proportion of youths with mood disorders than with behavior disorders, they were more likely to treat youths with behavior disorders because of the larger number of the latter (11.5% of 1,465 versus 13.9% of 820). Black youths were significantly less likely than white youths to receive specialty mental health or general medical services for mental disorders.

CONCLUSIONS

Findings from this analysis of NCS-A data confirm those of earlier, smaller studies, that only a minority of youths with psychiatric disorders receive treatment of any sort. Much of this treatment was provided in service settings in which few providers were likely to have specialist mental health training.

Impact of location and availability of behavioral health services for children

Literature suggests advantages for co-locating behavioral health care in primary care. We compared the impact of location of services on attendance at behavioral health appointments when access to care was assured for externalizing behavior problems with referral as usual. Two primary care pediatric practices had an evidence-based parenting program co-located in the practice for parents of children aged 2-12 years and two practices had the program available using an enhanced-referral procedure for locations external to the practices. The program was available at the regional children's hospital (referral as usual). During an 8-month period, the rate of attendance at first appointments was significantly higher in the co-located than the enhanced referral condition (.38 and .12 % of patient visits, respectively; χ(2) = 13.32; p < .0003; OR = 3.10; 95 % CI: 1.63, 5.89). These outcomes, while low, were better than the near 0 rate of attendance to referral as usual. Availability of behavioral health services in both conditions increased rates of attended appointments. However, the low rates of attendance indicate increasing availability of services, alone, is not sufficient to decrease the unmet need of children with behavioral problems. Factors other than availability must be addressed in order to improve outcomes for children.

Effectiveness of developmental screening in an urban setting

OBJECTIVE

To determine the effectiveness of developmental screening on the identification of developmental delays, early intervention (EI) referrals, and EI eligibility.

METHODS

This randomized controlled, parallel-group trial was conducted from December 2008 to June 2010 in 4 urban pediatric practices. Children were eligible if they were <30 months old, term, without congenital malformations or genetic syndromes, not in foster care, and not enrolled in EI. Children were randomized to receive 1 of the following: (1) developmental screening using Ages and Stages Questionnaire-II (ASQ-II and Modified Checklist for Autism in Toddlers (M-CHAT) with office staff assistance, (2) developmental screening using ASQ-II and M-CHAT without office staff assistance, or (3) developmental surveillance using age-appropriate milestones at well visits. Outcomes were assessed using an intention-to-treat analysis.

RESULTS

A total of 2103 children were enrolled. Most were African-American with family incomes less than $30,000. Children in either screening arm were more likely to be identified with delays (23.0% and 26.8% vs 13.0%; P < .001), referred to EI (19.9% and 17.5% vs 10.2%; P < .001), and eligible for EI services (7.0% and 5.3% vs 3.0%; P < .001) than children in the surveillance arm. Children in the screening arms incurred a shorter time to identification, EI referral, and EI evaluation than children in the surveillance arm.

CONCLUSIONS

Children who participated in a developmental screening program were more likely to be identified with developmental delays, referred to EI, and eligible for EI services in a timelier fashion than children who received surveillance alone. These results support policies endorsing developmental screening.

Ethnic differences in problem perception and perceived need for care for young children with problem behaviour

BACKGROUND

 Problem perception and perceived need for professional care are important determinants that can contribute to ethnic differences in the use of mental health care. Therefore, we studied ethnic differences in problem perception and perceived need for professional care in the parents and teachers of 5- to 6-year-old children from the general population who were selected for having emotional and behavioural problems.

METHODS

A cross-sectional study with data of 10,951 children from grade two of the elementary schools in the Rotterdam-Rijnmond area, The Netherlands. Parents and teachers completed the strengths and difficulties questionnaire (SDQ) as well as questions on problem perception and perceived need for care. The SDQ was used to identify children with emotional and behavioural problems. We included Dutch, Surinamese, Antillean, Moroccan and Turkish children in our sample with high (>P90) SDQ scores (N = 1,215), who were not currently receiving professional care for their problems.

RESULTS

Amongst children with high SDQ scores, problem perception was lower in non-Dutch parents than in Dutch parents (49% vs. 81%, p < 0.01). These lower rates of problem perception could not be explained by differences in socioeconomic position or severity of the problems. No ethnic differences were found in parental perceived need and in problem perception and perceived need reported by teachers. Higher levels of problem perception and perceived need were reported by teachers than by parents in all ethnic groups (PP: 87% vs. 63% and PN: 48% vs. 23%).

CONCLUSIONS

Child health professionals should be aware of ethnic variations in problem perception as low problem perception in parents of non-Dutch children may lead to miscommunication and unmet need for professional care for the child.

Enhancing the algorithm for developmental-behavioral surveillance and screening in children 0 to 5 years

OBJECTIVE

To determine if the 2006 American Academy of Pediatrics developmental surveillance and screening algorithm is adequate or if revisions are needed.

METHODS

A comprehensive literature search was conducted to investigate a clinician's ability to perform developmental-behavioral surveillance in children 0 to 5 years.

RESULTS

Even when a broad-band developmental screen is typical, pediatricians should refer when they confidently suspect a delay but be far more suspicious about children who seem asymptomatic. Periodic screening enhances surveillance by improving early detection and early intervention (EI) eligibility rates. Nevertheless, children with concerning screens are not consistently referred and interlinked to EI. Once referred, approximately half are deemed EI-ineligible, even though they typically perform well below average and have numerous, predictive academic and psychosocial risk factors. Meanwhile, clinicians struggle with tracking at-risk children.

CONCLUSION

Revisions are needed to optimize early detection, prevention, and monitoring. Greater emphasis is needed on developmental-behavioral promotion and referral care coordination.

The consultation as an interpretive dialogue about the child's health needs

BACKGROUND

Though uniquely placed in the health care system, GPs only become aware of a small number of children with behavioural and emotional problems. Research evaluating the challenges and barriers in general practice for identifying children with problems is therefore important.

OBJECTIVES

To identify and articulate GPs' experiences and perceptions of the GP-parent dialogue about children's health problems, in order to broaden our understanding of the challenges inherent to the dialogue.

METHODS

The GPs' experiences and recollections were explored in a qualitative study comprising four focus group discussions and nine individual interviews. The focus of study was to explore GP consultations with children 0-5 years of age and their parent/s.

RESULTS

Though expressing a family-focused approach to the child consultation, the GPs often did not succeed in making the consultation family focused. The analysis revealed that the GPs often were 'stuck' in the traditional role of expert and this made it difficult for them to explore the child's well-being. The consultation became more family focused when the GPs moved away from the role of expert. The GPs experienced that by sharing their uncertainty with parents, they often got more insight into the child's everyday life and family circumstances.

CONCLUSION

The study indicates that through open reflective dialogue the GP is able to assess the child and strengthen mutual trust in the doctor-parent relationship to the benefit of children with special needs.

Children's psychosocial problems presenting in a family medicine practice

Primary care physicians have an important role in identifying, treating, and referring children with psychosocial problems. However, there is a limited literature describing whether and how family physicians address psychosocial problems and why parents may not discuss children's problems with physicians. The current study examined how family physicians address psychosocial problems and reasons that parents do not discuss children's psychosocial problems with physicians. Results indicated that there are a variety of reasons involving parents, their perceptions of physicians, and the number of psychosocial problems reported, that may lead to fewer discussions of psychosocial problems.

Prevalence and correlates of mental disorders in a school-survey sample

Background:

Most of the adult mental disorders have their origins early in life. As the epidemiology of childhood psychiatric disorder in Italy has not been extensively investigated, we have evaluated the prevalence of mental disorders and their association with socio-familiar variables in a representative sample of children aged 6 to 11.

Method:

The study was conducted on a school- sample of 1028 children, aged 6 to 11, attending 12 primary schools in Florence (Italy). The diagnoses were made according to DSM IV diagnostic criteria, integrated by the description of each symptom, using specially trained teachers as lay-interviewers. Odds ratios with 95% C.I. chi squares and a stepwise binary logistic analysis have been performed.

Results:

Nine hundred ninety nine children (506 males; 493 females) were studied. Of them, 10.5% received a psychiatric diagnosis, with a higher prevalence in males (66.7% vs.33.3, p<0.01). The most prevalent groups of mental disorders were the behavioural/impulse control (7.2%) and anxiety (6.4%) disorders. Attention Deficit with Hyperactivity Disorder was the most represented diagnosis (5.6% of the children). All the other mental disorders were relatively rare, with only separation anxiety and overanxious disorder exceeding 1% prevalence.

Male gender, organic disease, having mother divorced, not present or dead, attending school full-time, cohabitation in the family were associated with an increased risk for any childhood mental disorder.

Conclusions:

About one in ten children aged 6-11 suffers from a mental disorder. Male gender, loss of mother and lower socio-economic status are associated with mental disorders in children. Further long-term prospective studies are needed, in order to clarify the epidemiological and psychopathological relationships between childhood and adult mental disorders.

Screening for anxiety disorders in children

Anxiety disorders are highly prevalent and have negative consequences on individual and societal level. This study examined the usefulness of screening for anxiety disorders in primary school children. More specifically, the value of the screening method to discriminate between and to predict anxiety disorders was studied. Children and their parents were selected if the children had self-reported scores on the screening questionnaire Screen for Child Anxiety Related Emotional Disorders-71 (SCARED-71) within the top-15% (High-anxious) or from two points below to two points above the median (Median-anxious). Of the selected children, 183 high-anxious children and their parents, and 80 median-anxious children and their parents took part in a diagnostic interview, the Anxiety Disorder Interview Schedule (ADIS). Of the high-anxious children, 60% had an anxiety disorder versus 23% of the median-anxious children, whereas groups did not differ on rates of dysthymia/depression and attention deficit hyperactivity disorder. The diagnoses separation anxiety disorder, social phobia and specific phobia were specifically predicted by the corresponding subscales of the screening questionnaire, while the diagnosis generalised anxiety disorder was not predicted by any of the subscales. The screening method has proven its utility for discriminating between children with and without anxiety disorders when applying the top-15% cut-off. Moreover, separation anxiety disorder, social phobia, and specific phobia, all known to be prevalent and debilitating childhood anxiety disorders, can be predicted by the corresponding subscale of the screening instrument.

Primary care and children's mental health in Brazil

OBJECTIVE

Primary care offers opportunities to expand children's access to mental health (MH) services, but a given practice's community context and staff attitudes may influence which integration models are feasible. The aim of this study was to explore the possibility of using community-based primary care to increase access to MH services in low-income communities in Brazil.

METHODS

A qualitative study was undertaken using focus groups with adolescents aged 11 to 16 (n = 46), parents (n = 40), and primary care clinicians and staff (n = 52) from public-sector health centers in 6 low-income Brazilian communities chosen for their geographic diversity.

RESULTS

Parents felt they had little support in parenting and attributed much of their children's behavior and mood problems to life in violent, poor communities. Parents thought that primary care could potentially be a source of MH care, but that clinicians often seemed rushed or uninterested. Clinicians classified many child problems as issues with parenting rather than MH. Nonprofessional staff was more likely to be a source of support to parents, except at one center that had a truly integrated MH service. Adolescents reported little need for MH services.

CONCLUSIONS

Expanding the role of primary care in child MH may require close attention to how parents, adolescents, and clinicians define their problems and on the causes to which they attribute them. These factors interact with differences in how centers organize MH care, and the extent to which they take advantage of patient interactions with nonprofessional staff.

Obstacles to mental health care in pediatric epilepsy: insight from parents

This exploratory study compared the responses of 20 Caucasian and 20 Hispanic mothers of children with epilepsy about possible obstacles to mental health care (MHC) for their children before and after they read a brochure on the neurobehavioral comorbidities of epilepsy. The intervention significantly increased the mothers' knowledge of the behavior and cognitive comorbidities of pediatric epilepsy and their treatment. Baseline differences in the attitude toward MHC and the stigma of epilepsy between Hispanic and Caucasian mothers were no longer apparent after the intervention. Irrespective of ethnicity, the mothers also became significantly more aware that their children did not want to have epilepsy-related behavior and learning difficulties. Efficient use of time spent in doctors' waiting rooms to educate parents about the neurobehavioral comorbidities of epilepsy can address the lack-of-knowledge barrier to MHC. However, the study's findings suggested a need to determine if there are specific obstacles to MHC in pediatric epilepsy.

A common factors approach to improving the mental health capacity of pediatric primary care

To expand the mental health service capacity of pediatric primary care, we ask whether there are evidence-based skills to allow providers to 1) immediately begin treatment for children with emotional and behavioral problems while diagnostic procedures are being pursued, and 2) offer evidence-based care to children who do not meet criteria for a specific diagnosis. We discuss why the epidemiology of child mental health problems poses difficulties for disorder-specific mental health interventions, and review evidence that "common factors" contributing to the outcome of mental health treatments define a core set of skills that primary care providers might use to complement disorder-specific interventions.

A common factors approach to improving the mental health capacity of pediatric primary care

To expand the mental health service capacity of pediatric primary care, we ask whether there are evidence-based skills to allow providers to 1) immediately begin treatment for children with emotional and behavioral problems while diagnostic procedures are being pursued, and 2) offer evidence-based care to children who do not meet criteria for a specific diagnosis. We discuss why the epidemiology of child mental health problems poses difficulties for disorder-specific mental health interventions, and review evidence that "common factors" contributing to the outcome of mental health treatments define a core set of skills that primary care providers might use to complement disorder-specific interventions.

"This is not normal ... "--signs that make the GP question the child's well-being

BACKGROUND

The GPs are uniquely placed to recognise children with mental problems and emotional stress that influence their well-being.

OBJECTIVES

The aim of the article is with focus on the GP's daily practice, to describe how the GP separates the healthy normal child's developmental crises from children with problems that need special attention and treatment.

METHODS

A qualitative research design is used based on material from focus-group discussions and individual interviews with 28 GPs from a Danish county. Data was analysed descriptively.

RESULTS

The GPs' attention was directed towards the contextual and relational sides. The GPs frequently became aware of a child in need during clinical work as a feeling of "this is not normal". This reaction could be triggered by the child's symptoms and problems, the parents' narrative of the child's daily life, the child's and the parents' communication and behaviour in the consultation, the family's use of the health care system and the doctor's knowledge of the family members.

CONCLUSION

The GP is used to observe and reflect on what happens in the consultation room. The GP might benefit from a systematic attention to the contextual issues. The GPs are frontline workers; they need a good dialogue with the experts and relevant supervision from them to meet the challenge of recognising children in need. It takes more than insight and will from the professionals, it requires a socio-political and socio-economic effort.

Communicating with children and families: from everyday interactions to skill in conveying distressing information

Health care communication is a skill that is critical to safe and effective medical practice; it can and must be taught. Communication skill influences patient disclosure, treatment adherence and outcome, adaptation to illness, and bereavement. This article provides a review of the evidence regarding clinical communication in the pediatric setting, covering the spectrum from outpatient primary care consultation to death notification, and provides practical suggestions to improve communication with patients and families, enabling more effective, efficient, and empathic pediatric health care.

An Innovative Treatment Approach for Children With Anxiety Disorders and Medically Unexplained Somatic Complaints

Anxiety disorders in children and adolescents are largely undetected and the majority of youth do not receive services. Given the deleterious consequences of anxiety disorders, early identification and intervention have public health implications. In order to increase identification and treatment of anxious youth, expansion to nonpsychiatric settings (i.e., pediatric medical settings, schools) is necessary. Pediatric medical offices represent ideal settings for detection and intervention for several reasons: (1) access to large numbers of children, (2) high prevalence of unrecognized anxiety disorders in medical settings, and (3) an association between anxiety disorders and medically unexplained somatic symptoms. This paper describes a cognitive-behavioral intervention for youth who present to pediatric medical settings with nonmedical somatic symptoms and undiagnosed anxiety disorders. We explain the rationale for and focus of our treatment approach, present two case studies illustrating the treatment process, and conclude with a discussion of implementation considerations.

Enhancing communication skills for pediatric visits through on-line training using video demonstrations

BACKGROUND

Training in communication skills for health professionals is important, but there are substantial barriers to individual in-person training for practicing clinicians. We evaluated the feasibility and desirability of on-line training and sought suggestions for future courses.

METHODS

Based on successful in-person curricula for communication skills and our previous on-line curricula, we created an on-line course consisting of 28 modules (4.75 hours CME credit) about communication skills during pediatric visits that included a mental health concern; each module included a brief case, a multiple choice question, an explanation, and a 1-2 minute video demonstrating key skills. Specific communication skills included: greeting, setting an agenda, discussing diagnosis and treatment, and managing negative interactions. The course was announced by emails in spring, 2007; the course was available on-line for 60 days; we aimed to enroll 50 clinicians. Outcomes were analyzed for those who evaluated the course within 75 days of its initial availability.

RESULTS

Overall, 61 clinicians registered, of whom most were nurses (N = 24), physicians (N = 22), or psychologists or social workers (N = 12). Of the 36 (59%) clinicians who evaluated the course, over 85% agreed that all course objectives had been met; over 90% reported greater confidence in greetings and agenda-setting; and over 80% reported greater confidence in discussing diagnosis and treatment and managing negative interactions. Nearly all, 97% would recommend the course to other clinicians and trainees. Suggestions for improvement included a library of additional video vignettes and written materials to accompany the on-line training.

CONCLUSION

On-line training in communication skills for pediatric mental health visits is feasible, desirable and associated with increased confidence in key skills. Positive feedback from clinicians suggests that a comparison of on-line versus in-person training is warranted.

Improving child and parent mental health in primary care: a cluster-randomized trial of communication skills training

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

Brief provider communication training had a positive impact on parent mental health symptoms and reduced minority children's impairment across a range of problems.

Predictors of Outpatient Mental Health Service Use by American Youth

Among American children and adolescents aged 1 to 17 years, the 12- to 17-year-olds represent the largest users of outpatient mental health services. This study utilizes a nationally representative sample of this age group from the 2005 National Survey on Drug Use and Health to illuminate predictors of services use from three treatment settings: day treatment programs, mental health clinics/centers, and private/in-home settings. Univariate analyses were used to calculate the percentages of the study sample that used mental health services in these settings. In bivariate analyses, the authors estimated the strength of the associations between available predisposing, need, and enabling factors and the outcomes. Multiple logistic regressions estimated the independent effects of each covariate on the outcomes. Lifetime depression, lifetime general anxiety, delinquent behaviors, drug dependence, and Medicaid were consistent predictors of services use in the three treatment settings. Several other factors were associated with services use in bivariate analyses but lost most of their statistical significance when the authors adjusted for other confounders. Interpreted in light of its potential limitations, this study has important research and policy significance.

Unmet mental health needs in pediatric epilepsy: insights from providers

Eighteen pediatric neurologists and 18 pediatricians completed a 5-point Likert scale questionnaire on their knowledge of, attitudes toward, and management of the behavioral, cognitive, and psychosocial aspects of pediatric epilepsy, before and after a lecture on this topic. They also responded to questions about possible barriers to mental health care of children with epilepsy. The brief educational intervention modified the knowledge/attitudes of pediatricians compared with pediatric neurologists on the impact of epilepsy on behavior and cognition in children with epilepsy. However, there were no between-group differences in how providers perceived their competence to assess behavioral and cognitive comorbid conditions in pediatric epilepsy. Responses to open-ended questions suggested insufficient mental health coverage for and expertise on pediatric epilepsy, resistance of mental health clinicians to treat children with epilepsy, and the stigma of mental health as possible barriers to mental health care in children with epilepsy. In addition to the need for provider education about the behavioral and cognitive comorbid conditions of pediatric epilepsy, these findings emphasize the importance of examining alternative routes to increasing mental health care for children with epilepsy.

Physician and patient characteristics associated with discussion of psychosocial health during pediatric primary care visits

This study examined whether physical pain, mental health symptoms, and provider characteristics were associated with the discussion of children's behavior, mood, getting along with others, school performance, family stress, and parent stress during 800 pediatric primary care visits to 54 providers in 13 clinics. The discussion of psychosocial health was more common when the child demonstrated hyperactivity symptoms, the visit was for a mental health problem, and the provider was a woman or reported greater confidence in mental health treatment skills, but less common when the child demonstrated physical pain. Provider gender, psychosocial orientation, the reason for the visit, and the child's characteristics did not explain the inverse relationship between pain and discussion. This suggests that multilevel factors that describe the child and provider are associated with the discussion of psychosocial health, and that pain interferes with discussion during all types of visits and during visits with children who are impaired by mental health symptoms.

Parent-provider communication and parental satisfaction with care of children with psychosocial problems

OBJECTIVE

The objective of the present paper was to determine the association between parent-provider communication and parent ratings of satisfaction and quality of care for a group of parents of children identified with a psychosocial problem.

METHODS

A sample of 804 parents of children with psychosocial concerns enrolled in the Child Behavior Study (CBS) was used for the present analyses. As part of the CBS, parents of children with psychosocial problems answered questions that assessed parent-provider communication and parent ratings of satisfaction and quality of care.

RESULTS

Overall, parents reported good communication with their child's provider. Eighty-two percent of parents were very satisfied with the care received and 68% reported a very high quality of care. Parent-provider communication (e.g., collaboration and mutual understanding) was strongly related to parental reports of both satisfaction and quality of care.

CONCLUSIONS

Parent-provider communication is an important correlate of parental report of satisfaction and quality of care. Involvement of parents in the treatment planning process was particularly important in determining satisfaction and quality ratings within this sample.

PRACTICE IMPLICATIONS

When working with families with identified psychosocial concerns, the use of collaboration and an empathic style by providers may enhance the quality of care parents report receiving from their primary care clinicians.

Identification of youth psychosocial problems during pediatric primary care visits

This investigation applied the Gateway Provider Model (GPM) of child mental health services to investigate whether characteristics of the child, family, visit, and provider were related to the identification of youth psychosocial problems during primary care visits. Data were gathered during 774 visits to 54 primary care providers (PCPs) at 13 clinics. Similar to previous investigations in primary care settings, 42% of youth demonstrated at least a sub-threshold clinical mental health problem. Most PCPs reported high job satisfaction and control, but reported varying access to mental health specialists. PCPs generally had positive attitudes and beliefs about treating psychosocial problems but many reported that doing so was burdensome. Identification was more likely when the visit was for a mental health problem, when issues related to psychosocial problems were discussed during the visit, when the youth demonstrated mental health symptoms, impairment, or burden to the family, and when the youth was older, uninsured, or received Medicaid. Identification was less likely when the PCP reported greater burden associated with treating psychosocial problems and when the PCP reported greater accessibility to mental health specialists. These results suggest that identification is associated with the interaction of multilevel factors and that the GPM is a useful model to investigate points of intervention for improving the identification of children's mental health problems in primary care settings.

Early maturation as a risk factor for aggression and delinquency in adolescent girls: A review

Early physical maturation has long been considered a risk factor for the development of delinquent girls. The basis of this relationship has not been fully explored or understood. This review summarises the current literature and research on early physical maturation in adolescent females and places it within a developmental perspective. The process of early physical maturation is also placed within a biopsychosocial model so that risk and protective factors arising from the biological, social, family, education and peer environments can be ascertained. A complex model of maturation and environmental-social interaction is constructed and currently supported by research, but it is clear that a great deal of further work is necessary to fully understand this process.

Annotation: Pathways to care for children with mental health problems

BACKGROUND

Although many children with mental health problems are in contact with primary health care services, few receive appropriate help.

METHODS

Using a pathways to care model, this paper systematically reviews the literature relating to access to services. It separates out the various stages of help-seeking: parental perception of problems, use of primary care services, recognition within primary care, and referral to or use of specialist health services.

RESULTS

Following parental awareness of child symptoms, parental perception of problems is the key initial step in the help-seeking process. Although children with mental health problems or disorders are regular attenders within primary care and most parents acknowledge that it is appropriate to discuss concerns about psychosocial issues in this setting, few children are presented with mental health symptoms even if their parents have such concerns. Subsequently, less than half of children with disorders are recognised in primary care. Amongst recognised children, about half are referred to specialist services. Overall, up to one-third of children with disorders receive services for mental health problems. Factors such as the type and severity of disorder, parental perceptions, child age and gender, and family and social background factors determine which affected children access services.

CONCLUSIONS

As there are inequities in patterns of service use, a greater emphasis on developing resources at population and primary care levels is required. Barriers involving parental perceptions and expression of concerns within consultations should be minimised at these levels. This requires both public education approaches and improved training and specialist support for primary care services to enhance their ability to provide for these children.

The role of care location in diagnosis and treatment of pediatric psychosocial conditions

Racial differences in diagnosis and treatment of psychosocial conditions have been well documented. It is unclear if these differences represent variance in prevalence or are actually disparities in care driven by social factors, income-related differences, or differences in the actual location of care. We used 4 years of National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys as source for data on visits to private offices and hospital-based clinics. In addition to the standard practice of combining surveys across years, we used a "supersurvey" approach to combining the 2 distinct surveys. In our roughly 20,000 sampled visits, we confirmed the higher concentration of low-income children in visits to hospital-based clinics (p <.001), but saw no significant racial difference (p =.104). After controlling for race, income, and other demographics, we found that visits to hospital-based clinics were significantly more likely to include a diagnosis of depression (odds ratio [OR], 4.4; p =.011), but that there was no statistically significant difference in other psychosocial diagnoses. Once a diagnosis is made, there is no evidence of differences in treatment or follow-up between office-based or hospital clinic-based providers. Our analyses support previously gathered evidence for differences in economic status of the clientele of private offices and hospital-based clinics. We surprisingly found visits to clinics to be more likely to include a depression diagnosis, but this may be an artifact of the data reflecting visits rather than patients. We found no evidence that treatment or follow-up is different for the disadvantaged who use clinics rather than private offices.

Unmet need and problems accessing specialty medical and related services among children with special health care needs

OBJECTIVES

To extend what is known about parent reports of their child's need for specialty medical and related services, unmet need, and specific types of access problems among children with special health care needs (CSHCN).

METHODS

Using data from a 1998-1999 20-state survey of families of CSHCN, we examined differences in parent report of need for services by child characteristics, investigated parent report of unmet need and access problems by service area and number of services needed, and estimated the likelihood of four access problems and unmet need by child, family, and health insurance characteristics.

RESULTS

Overall, the sample children had numerous service needs, although the prevalence of need varied by service type and child characteristics. Reports of unmet need were greater for older children and for children with multiple service needs, unstable health care needs or a behavioral health condition, parents who were in poor health or had more than a high school education, and families whose insurance coverage was inconsistent or lacked a secondary plan. Reports of access problems were greatest for mental health and home health services. The two most prevalent access problems were finding a skilled provider and getting enough visits.

CONCLUSIONS

The results underscore the importance of finding new ways to link children with behavioral health problems to mental health services, implementing coordinated care and the other core dimensions of the medical home concept, increasing the number of specialty pediatricians and home health providers, and expanding coverage for a wider range of mental health services.

10-year research update review: the epidemiology of child and adolescent psychiatric disorders: I. Methods and public health burden

OBJECTIVE

To review recent progress in child and adolescent psychiatric epidemiology in the area of prevalence and burden.

METHOD

The literature published in the past decade was reviewed under two headings: methods and findings.

RESULTS

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.

CONCLUSIONS

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.

Family-based services in children's mental health: a research review and synthesis

A systematic review was undertaken of scientifically rigorous studies of family-based services in children's health and mental health. From a pool of over 4000 articles since 1980 in health and mental health that examined either specific family-based interventions for families of children or the processes of involvement, 41 studies were identified that met the methodological criteria for inclusion. These 41 studies encompassed 3 distinct categories: families as recipients of interventions (e.g., family education, support, engagement, empowerment); (b) families as co-therapists; and (c) studies of the processes of involvement (e.g., therapeutic alliance, engagement, empowerment, expectancies, and choice). Too few experimental studies exist to conclude decisively that family-based services improve youth clinical outcomes. However, those studies that have been rigorously examined demonstrate unequivocal improvements in other types of outcomes, such as retention in services, knowledge about mental health issues, self-efficacy, and improved family interactions - all outcomes that are essential ingredients of quality care. Four implications are drawn from this review. (1) Effective family education and support interventions from studies of adults with mental illnesses and from studies of families of high-risk infants exist and can be imported into the field of children's mental health. (2) The range of outcomes that are typically assessed in clinical treatment studies is too narrow to afford an adequate view of the impact of family-based interventions. A broader view of outcomes is needed. (3) The absence of a robust literature on process variables other than therapeutic alliance limits conclusions about how and why interventions are effective. Attention to the processes by which families become involved in services will require a more robust and nuanced range of studies that attend simultaneously to processes of change and to outcome improvement. (4) Linkage of effective family-based interventions to delivery of evidence-based services is likely to amplify the impact of those services and improve outcomes for youth and families.

Pediatric residents' responses that discourage discussion of psychosocial problems in primary care

OBJECTIVE

Studies spanning nearly 4 decades demonstrate that doctors ignore or dismiss many patient bids for discussion of psychosocial topics. We sought to understand characteristics of doctors, patients, and visits in which this occurs.

METHODS

Reanalysis of 167 audiotapes from 2 studies of parent-doctor communication in a pediatric residents' continuity clinic was performed. Tapes included visits by 100 mothers or female guardians to 55 residents who were the children's primary care providers. Coders identified mentions of psychosocial topics and noted the content and the doctor's response. Responses were classified with an adaptation of a previously described, psychoanalytically derived typology of avoidant or discouraging responses.

RESULTS

Discouraging responses occurred in 34 (77%) of 44 discussions that involved corporal punishment and 51 (34%) of 64 discussions that involved other psychosocial topics. The particular topic (parent/family versus routine parenting issue) and how the topic was framed (as a problem versus simply mentioned) were associated with doctors' discouraging responses (OR: 3.07; 95% confidence interval: 1.56-6.05; and OR: 7.57; 95% confidence interval: 3.50-16.44; respectively). Discouraging responses were not related to the doctor's gender, parent's ethnicity, length of the parent-doctor relationship, or doctor's overall interview style (patient-centeredness). Discouraging responses to routine problems tended to be dismissive, but 41% of discouraging responses to parent/family problems were failed attempts to provide advice.

CONCLUSIONS

Discouraging responses seem to be related less to doctor or patient characteristics than to the type and acuity of the psychosocial topic. These responses may originate with doctors' discomfort with particular subject areas and thus might be approached with training that combines communication and emotion-handling skills with clinical tools such as Bright Futures in Practice: Mental Health or the International Classification of Diseases, 10th Revision, Primary Care.

Psychosocial problems among immigrant and non-immigrant children--ethnicity plays a role in their occurrence and identification

BACKGROUND

This study aims to examine a) the prevalence of psychosocial problems and b) the association between parent-reported problems and the identification by doctors and nurses (child health professionals, CHP) working in preventive child health care, among immigrant and non-immigrant children.

METHODS

CHPs examined 4,098 children aged 5 through 15 years (response: 90.1%) and interviewed parents and children during their routine health assessments in 19 Child Healthcare Services across the Netherlands, serving nearly all school-aged children routinely. The Child Behavior Checklist (CBCL) was completed by the parents. We compared five ethnic groups: indigenous Dutch, economic immigrants, immigrants from (former) Dutch colonies, from other non-industrialised, and from other industrialised countries.

RESULTS

The prevalence of parent-reported problems on the CBCL is higher among children from former Dutch colonies and economic immigrant children than among indigenous children, especially regarding internalizing problems (odds ratios (OR); 95% confidence interval: 1.84; 1.03 to 3.29, and 2.52; 1.46 to 4.34). CHPs identified more problems among economic immigrant children (OR: 1.62; 1.01 to 2.60). Regarding associations, rates of CHP-identified problems were higher among indigenous children with clinical compared with normal CBCL Total Problems scores (OR: 6.90; 5.27 to 9.03), but not among economic immigrant children (OR: 0.73; 0.16 to 3.21).

CONCLUSIONS

Psychosocial problems occur more frequently among some immigrant groups. CHP identification of psychosocial problems is poorly associated with parent report regarding economic immigrant children. This needs to be improved in order to provide better care.

School district resources and identification of children with autistic disorder

OBJECTIVES

We estimated the effect of community and school district resources on the identification of children with autistic disorder.

METHODS

Latent growth curve regression models were applied to school district-level data from one large state.

RESULTS

The rate of identification of autistic disorder increased on average by 1.0 child per 10000 per year (P<.001), with statistically significant district variation. After adjustment for district and community characteristics, each increase in decile of school revenue was associated with an increase of 0.16 per 10000 children identified with autistic disorder. The proportion of economically disadvantaged children per district was inversely associated with autistic disorder cases.

CONCLUSIONS

District revenue was associated with higher proportions of children identified with autistic disorder at baseline and increasing rates of identification when measured longitudinally. Economically disadvantaged communities may need assistance to identify children with autistic spectrum disorders and other developmental delays that require attention.

Screening for childhood anxiety symptoms in primary care: integrating child and parent reports

OBJECTIVE

Parents' concerns typically determine the focus of a primary care visit. This study examined which information is lost if child reports are excluded from screening for anxiety. It also explores the use in primary care of the Screen for Child Anxiety Related Emotional Disorders (SCARED) and the Pediatric Symptom Checklist (PSC-17).

METHOD

Two hundred thirty-six children (8-12 years 11 months) and their parents completed SCARED and PSC-17 before a primary care visit occurring during discrete periods between June 1999 and March 2001.

RESULTS

Child reports yielded higher SCARED scores than parent reports (mean=18.12, SD=12.14 versus 14.43, SD=10.34, p <.001). Somatic/panic and separation anxiety accounted for 73.8% of the excess score from children's reports. The level of parent-reported symptoms did not vary with demographics. Female gender and younger age predicted greater excess reporting by children. Parent and child scores were moderately to highly correlated (R=0.55 total score; 0.40-0.58 subfactors).

CONCLUSIONS

There are discrete anxiety domains in which children's reports are likely to yield more information than that of parents. This phenomenon is almost entirely attributable to variations in the level of symptoms reported by children. Studies are needed to design brief screening procedures that integrate parent and child reports and carry age- and gender-adjusted thresholds.