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About the PSC
Background and initial research on the PSC
Childhood psychosocial problems, considered “the new morbidity" thirty years ago, has become widely acknowledged as one of the most common, chronic conditions of children and adolescents (Haggerty et al., 1975; Kelleher et al., 1996). Epidemiologic studies report that 12-25% of all American school-age children and 13% of preschoolers have an emotional and/or behavioral disorder. (Costello et al., 1988; Costello et al., 1988; Brandenburg et al., 1990; 1990; Lavigne et al., 1993; Costello et al., 1996). The rates of psychosocial impairment are higher in risk groups such as low income and/or single parent households.
Pediatricians have long been an important first resource for parents who are worried about their children's behavioral problems (Sharp et al., 1992). With the advent of managed care and especially capitated systems, (Eisenberg, 1997) primary care providers assume an even greater "gatekeeping" responsibility to identify, manage, and refer children with emotional and/or behavioral disorders (Jellinek, 1994). However, studies estimate that only about 50% of these children are identified by their primary care physicians and that once identified, only a fraction of these children receive appropriate mental health treatment.(Jellinek, 1982; Starfield, 1982; Costello, 1986; Sharp et al., 1992).
A number of studies (Ryan et al., 1992; Kelleher et al., 1998) have documented an increasing prevalence of behavioral and emotional problems in the U.S. and other countries in children and adults. Despite the growing burden of psychosocial morbidity, pediatricians still do not receive adequate training concerning psychosocial problems, (Wissow et al., 1994) are hesitant to attach potentially deleterious labels to children, (Costello, 1986) do not have time during office visits to address psychosocial needs, and may have limited access to mental health referral networks.(Jellinek, 1982). Efforts such as the American Board of Pediatrics increasing ambulatory and behavioral training requirements, publications such as Bright Futures, (Green, 1996), Bright futures: Mental Health (Jellinek et al., 2002a), and the Diagnostic and Statistical Manual for Primary Care (DSM-PC; American Academy of Pediatrics, 1996) have helped to increase awareness of psychosocial morbidity over the long-term, but as of now, primary care pediatricians still struggle to provide psychosocial services (Kelleher et al., 1996). The move to managed care approaches in medicine and the increasing focus on productivity and profitability has created an additional pressure for pediatric clinicians to limit attention on psychosocial problems.
One way to counterbalance this pressure is to use a parent-completed screening questionnaire as part of routine primary care visits (Sturner, 1991) to facilitate recognition and referral of psychosocial problems. The Pediatric Symptom Checklist (PSC) was developed for this purpose. The PSC is a one-page questionnaire listing a broad range of children's emotional and behavioral problems that reflects parents' impressions of their children's psychosocial functioning. Cutoff scores for pre-school and school-age children indicating clinical levels of dysfunction have been empirically derived using Receiver Operator Characteristic analyses in studies comparing the performance of the PSC to other validated questionnaires and clinicians' assessments of children's overall functioning (Jellinek, 1986; Jellinek et al., 1986; Little et al., 1994).
In a number of validity studies, PSC case classifications agreed with case classifications on the Child Behavior Checklist (CBCL), Children's Global Assessment Scale (CGAS) ratings of impairment, and the presence of psychiatric disorder in a variety of pediatric and subspecialty settings representing diverse socioeconomic backgrounds. (Jellinek et al., 1988; Jellinek et al., 1991; Rauch et al., 1991; Murphy et al., 1992a; Murphy et al., 1996). When compared to CGAS in both middle and lower income samples, the PSC has shown high rates of overall agreement (79%; 92%), sensitivity (95%; 88%) and specificity (68%; 100%) respectively, (Jellinek, 1986; Jellinek et al., 1988; Murphy et al., 1992a)
Studies using the PSC have found prevalence rates of psychosocial impairment in middle class or general settings (~12%) that are quite comparable to national estimates of the prevalence of psychosocial problems (Jellinek et al., 1988; Jellinek et al., 1991; Rauch et al., 1991; Murphy et al., 1992a; Little et al., 1994; Murphy et al., 1996). More recently, efforts to develop specific subscales of the PSC for use in identification of attentional, internalizing (depression/anxiety), and conduct problems (Gardner et al., 1999) and to develop a youth self report version (Gall et al., 2000; Pagano et al., 2000) of the PSC are well along .
Previous studies using a variety of measures have consistently shown that the prevalence of psychosocial impairment varies considerably based on a number of socio-demographic risk factors, and research with the PSC has paralleled many of these findings. For example, low socioeconomic status (Jensen et al., 1990), living with a single parent (Rutter, 1981), parental mental illness (Orvaschel et al., 1981; Pfeffer et al., 1986), family discord (Earls and Jung, 1987), the child's temperamental characteristics, and male sex (Earls and Jung, 1987; Kashani et al., 1987) have all been shown to increase the probability of psychosocial dysfunction. Consistent with these findings, studies using the PSC have shown the prevalence of child psychosocial dysfunction to be two to three times higher in children from low income (Murphy et al., 1992a), single-parent (Murphy et al., 1992a) and/or mentally ill parent families (Jellinek et al., 1991).
Some investigators have recommended that the PSC should be considered "basic office equipment" in pediatrics and others have argued that the PSC should become a mandated part of all well-child visits in managed care settings or large programs like Medicaid EPSDT.(Sturner, 1991; Murphy et al., 1996; Pagano et al., 1996). Several states (e.g., Arizona, Massachusetts) now recommend the PSC or other brief questionnaires for psychosocial screening during EPSDT, and a number of HMO’s (Kaiser of Northern California, Neighborhood Health Plan of Massachusetts) are piloting the use of the PSC as a routine part of well-child visits. The PSC is also being used as a part of annual screenings in a variety of non-health care settings like Ventura County, California Head Start (Jellinek et al., 2005).
Research on the PSC and psychosocial screening in pediatrics over the past decade
When we first summarized the research on the PSC for our website, we reviewed publications up to the late 1990’s. At that time, we listed twenty studies about the PSC, with most of these devoted to its validation (Jellinek et al., 1986) or to its use as a marker for psychosocial dysfunction in general (Jellinek et al., 1988) or specialty (Rauch et al., 1991) pediatric populations. Over the ensuing decade there have been more than four dozen new studies with the PSC. An additional half dozen or so papers have been reviews of the PSC and other similar instruments. As of this writing, the PSC is also listed as a recommended screening instrument in reviews posted on the websites of at least a half dozen states (see below) and several children’s advocacy organizations including the Section of Developmental and Behavioral Pediatrics of the American Academy of Pediatrics and the Bazelon Center for Mental Health Law (Bazelon, 1997). Reports on these initiatives and all of the new published studies will be reviewed briefly below.
Our review of recent (through 2007) studies about the PSC and psychosocial screening since 1996 will follow the same general outline as the original section above, beginning with 1) a review of recent work on the prevalence of psychosocial problems in children, 2) then a look at current thoughts on psychosocial screening, and then 3a) on to new studies exploring the PSC’s validity, 3b) its use as a marker of psychosocial dysfunction in a wide range of medical and educational studies, 3c) its use as an outcome measure in psychiatric and educational interventions, and 3d) its use as a clinical measure in programs designed to increase the integration of health and behavioral healthcare in pediatrics.
1. Recent work on the prevalence of psychosocial problems in US children
First of all, the past decade has produced a continuing stream of empirical and expert support for the notion that psychosocial dysfunction is one of the leading sources of problems among children. Both large studies (Kelleher et al., 2000; Blanchard et al., 2006), and pediatric authorities (American Academy of Pediatrics, 2001) have continued to endorse the view that psychosocial problems are a major concern for children and families in the US and that primary care pediatricians are already concerned about them but should be doing even more as a part of routine care. Supporting these studies are others which have continued to document the fact that roughly half of all pediatric visits and half of all parent concerns during these visits are related to psychosocial problems (Wren et al., 2003).
2. A look at current thoughts on psychosocial screening in pediatrics
The need to focus more attention on children’s psychosocial problems has been underscored and raised to the level of policy recommendations by national benchmarking efforts like Healthy People 2010 (USDHHS, 2000a). Healthy People 2010 contains the official health goals for US health as determined by the Surgeon General and two of the current HP 2010 goals relate directly to psychosocial screening in pediatrics:
These recommendations for an increased focus on psychosocial problems in primary care have been echoed by and to some extent stem from the US Surgeon General’s most recent report on children’s mental health (USDHHS, 2000b). The report of the most recent presidential task force on mental health (USDHHS, 2003) continues this major emphasis on routine screening in primary care.
Routine screening for psychosocial problems in pediatrics has also become a matter of policy in the guidelines for Medicaid (Adams et al., 1998) the health insurance program that provides healthcare for twenty million of the nation’s poorest children (USDHHS, 1997). The settlement of a recent lawsuit in Massachusetts (Goldberg, 2007) is merely the latest is a series of legal challenges in more than a dozen states, all of which have come to the same conclusion, namely that screening for mental health and developmental problems must be a part of all well-child visits covered by Medicaid under its Early Periodic Screening Diagnosis and Treatment program (Semansky et al., 2003).
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A series of reviews conducted by the Bazelon Institute (Bazelon, 1997; (Semansky et al., 2003) have found evidence that although they are inconsistent in the rigor of their implementation and follow through, most states do require mental health screening as a part of their EPSDT programs. In the Bazelon reviews, the PSC has been found to be the measure most commonly recommended for general psychosocial screening for school aged children. Other instruments are recommended for screening younger children or teenagers or to screen for substance abuse. The PSC is currently recommended for psychosocial screening in pediatrics on the websites of at least a half dozen states: Arizona (Pinal/Gila Long Term Care, 2007), Massachusetts (Massachusetts Behavioral Health Partnership, 2004), Minnesota (Minnesota Department of Health, 2007), North Carolina (North Carolina Department of Mental Health and Human Services, 2007), New York (New York State Office of Mental Health, 2006), Tennessee (Tennessee Department of Mental Health and Developmental Disablities, 2007).
Over the past year, the practice of routine screening for psychosocial problems in pediatrics took two major steps forward in Massachusetts. First of all, the state’s largest three insurers, including Blue Cross Blue Shield have begun to reimburse pediatricians for this kind of screening at rates ranging from $15 to $20 per screen (Massachusetts Chapter of the American Academy of Pediatrics, 2007). Secondly similar policies and a reimbursement of about $10 are now mandated for patients with Medicaid health insurance (Goldberg, 2007).
Although the results of these new policies in Massachusetts have not been tabulated, let alone evaluated as to their effectiveness, it is hard to imagine that rates of psychosocial screening will not go up as a result of making screening reimbursable. A more interesting question is whether, as hoped for by expert opinion like Healthy People 2010, implementing routine psychosocial screening will have a measurable impact on children’s mental health or overall health. This could be an area for fruitful research in the future.
In the meantime, it is clear that the PSC is one of the most frequently recommended instruments for children with both Medicaid and commercial health insurance and that the vast majority of studies over the past decade have shown the PSC’s usefulness as a marker for psychosocial dysfunction. The use of the PSC as a marker and its more recent application as an outcome measure for intervention studies, when added to the general category of new studies assessing the validity of the PSC, provide a simple way of describing the types of studies which have been done with the PSC over the past decade and each will be reviewed in turn, beginning with the latter.
3a. New studies exploring the validity of the PSC
One reason that the PSC continues to be listed as a recommended instrument is that virtually all of the studies that have assessed it have found it to be valid and reliable. With one important caveat, all two dozen or so studies that assessed the validity of the PSC in various heterogeneous or homogeneous subpopulations have confirmed it. The one caveat concerns the specific cutoff score to use to indicate dysfunction and/or the need for further evaluation in any given population. Although two of the largest and most diverse samples studied to date (Kelleher et al., 1998; Bernal et al., 2000) have found that the originally recommended cutoff score of 28 for school aged children appears to be optimal and that this cutoff appeared to be correct for most of the many subgroups studied (Jellinek et al., 1999), a number of other studies have suggested the need to determine the optimal cut off score when new populations are studied. These findings will be reviewed below.
Although the PSC was well-validated in the 1980’s and 1990’s, new studies assessing the validity of the PSC were necessitated when it was used with new populations, in both ethnic population subgroups in the US and in non US samples. Over the past decade, the PSC has been translated into many languages and used in studies in more than a dozen countries on all of the major continents. Published studies have documented the validity of the PSC in Japan (Ishizaki et al., 1997; Ishizaki et al., 2000; Ishizaki et al., 2002; Oyama et al., 2002; Ishizaki et al., 2005a; Ishizaki et al., 2005b; Ishizaki et al., 2006), Holland (Reijneveld et al., 2006), Austria (Herzog et al., 2007) and Chile (De la Barra et al., 2005). Unpublished studies have also been conducted in the Philippines, India, Israel, Korea, Tanzania, and Australia.
The PSC has also been validated for use with specific ethnic subgroups within the US, including Mexicans (Leiner et al., 2007) and Mexican-Americans (Jutte et al., 2003) seen in low income US communities. The caveat about the need to establish an appropriate cutoff score was particularly important for the latter study where optimum sensitivity and specificity were found using a cutoff score of 12. The former study broke new ground by validating the use of a pictorial form of the PSC.
3b. Studies using the PSC as a marker for psychosocial dysfunction
By the mid 1990’s, the PSC had been validated in traditional pediatric practices serving both white middle class (Jellinek et al., 1986; Jellinek et al., 1988) and minority/low income samples (Jellinek and Murphy, 1988; Murphy et al., 1992a; Murphy et al., 1992b) Beginning in the mid 1990’s, the first papers from a national sample that used the PSC began to come out. With funding from the National Institute of Mental Health, Kelley Kelleher and his colleagues launched the Child Behavior Study in a nationally representative sample of more than 20,000 children seen in US pediatric and family practice offices. This study has already resulted in more than a dozen published papers (Kelleher and Wolraich, 1996; Kelleher et al., 1998; Gardner et al., 1999; Kelleher et al., 1999; Wasserman et al., 1999; Kelleher et al., 2000; Gardner et al., 2001; Palermo et al., 2002; Gardner et al., 2002a; Gardner et al., 2003; Walders et al., 2003; Wren et al., 2003; Gardner et al., 2007); most of which explore pediatrician recognition of psychosocial problems in a large national sample of pediatric and family practice visits. In general these studies confirmed previous estimates of about 12% prevalence of psychosocial problems and that these problems were under-recognized and under-referred. These studies also examined the impact of insurance, gender, race, and other factors on patterns of recognition and referral and the relationship between PSC and related measures like family functioning and physician attitudes.
A by-product of the CBS study is that Gardner and Kelleher used the power of the large number of cases in their sample (20,000+) to develop a briefer version of the PSC. Their studies have provided both statistical (Gardner et al., 1999) and clinical (Gardner, 2007) validation for a 17 item form of the PSC. Other authors have used this form (Borowsky et al., 2003; Duke et al., 2005; Ohene et al., 2006; Miller et al., 2007). Although its properties are similar to those of the original PSC 35 form, studies (Gardner et al., 1999; Gardner et al., 2007) do suggest a somewhat greater degree of accuracy with the original form, so it is still the instrument of choice unless time pressures mandate the use of the briefest possible screen.
In addition to the Kelleher et al CBS studies cited above, another dozen studies have used the PSC as a marker to explore the prevalence of psychosocial problems in other pediatric settings like HMO’s (Bernal et al., 2000; Navon et al., 2001), low income practices billing Medicaid (Murphy et al., 1996), State Children’s Health Insurance Programs (SCHIP; (Brickman et al., 2002)) and well-child vs. sick visits (Borowsky et al., 2003). These studies have generally confirmed a higher than average prevalence rate of psychosocial problems among poor children and/or under-recognition and under-referral.(Murphy et al., 2008).
Another group of studies have used the PSC to explore the prevalence of psychosocial problems among children with specific pediatric problems like thalesemia (Louthrenoo et al., 2002; Saini et al., 2007), dermatological conditions (Hansen, 1997), hunger (Miller et al., 2007), neurological problems (Anderson et al., 1999) and mental retardation (Harrison et al., 2006). These studies have generally shown that PSC positive rates are two to three times more prevalent in children with chronic conditions.
3c. Use of the PSC as an outcome measure for intervention studies
The PSC is increasingly being used as a pre-post measure to assess the impact of interventions. Studies have shown significant decreases in PSC scores for children who receive mental health interventions in a child psychiatry clinic that are comparable to those found with other standardized measures at (Murphy et al., 2007; Murphy, 2007; Murphy et al., 2008) and another has used the PSC as an outcome measure to assess the impact of a school based mental health intervention (Stein et al., 2003). The PSC has also been used to assess the effects of school breakfast programs (Murphy et al., 1998; Kleinman et al., 2002), with significant improvements of functioning demonstrated in all studies.
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3d. Use of the PSC as a clinical measure for integrated healthcare models
The PSC has also been used as clinical measure in a number of large public health initiatives. The Cambridge Health Alliance has mandated psychosocial screening with the PSC in a number of its outpatient facilities for the past three years and research already published (Hacker et al., 2006) has shown the PSC can be implemented for routine use and combined with other innovative elements in an integrated approach to health and behavioral health in a large urban pediatric system of care. Preliminary research in progress is focused on determining how the PSC performs over time in a sample population and what factors contribute to change in PSC score. (Hacker et al 2007).
The Cambridge Health Alliance Pediatric Mental Health Screening and Intervention project was funded by the U.S.Maternal and Child Health Bureau as one of six sites selected to implement an innovative model as part of its Integrated Health and Behavioral Healthcare Initiative. All six implementation sites chose the PSC as the measure to use for the screening component of their integrated health and behavioral health initiatives (Murphy and Wieneke, 2006). The Cambridge Alliance project was originally funded through the Healthy Tomorrows program, another project of MCHB (and the American Academy of Pediatrics) that also advocated for increased coordination of services in pediatrics.
The PSC was also mentioned prominently in Bright Futures Mental Health (Jellinek et al., 2002a; Jellinek et al., 2002b), another joint project of MCHB and AAP that advocated for more integrated health and behavioral healthcare. BFMH has achieved worldwide dissemination and made psychosocial screening more accessible to pediatric practices by including measures like the PSC that could be photocopied and distributed as well as instructions for their use and recommendations for clinical practices that would lead to more integrated health and behavioral healthcare.
Conclusion
Over the past decade the PSC has continued to serve as an easy-to-use tool that is broadly valid and reliable and can meet a growing array of therapeutic, research, and administrative assessment needs in a wide range of clinical, educational, and public health settings in the US and other countries. We expect additional studies using the PSC in pediatric settings now that it is mandated in Massachusetts and many other states for all children enrolled in Medicaid…and reimbursing pediatricians in this and other states should also increase its use. In the field of mental health, the PSC has been used as an outcome measure in an outpatient child psychiatry clinic and has demonstrated preliminary validity and utility. Educational uses of the PSC have also expanded from a screen and a marker in some Head Start and school breakfast programs to one of the cornerstones of national screening program that has grown to more than 25,000 students per year in Chile (JUNAEB, 2007). The Chilean program has also incorporated a comprehensive intervention and prevention program in conjunction with routine screening…and preliminary results suggest that this program has had a significantly positive impact on educational outcomes.
With datasets in public health, psychiatric, and educational settings growing we expect to work more extensively with subscales. For example the Chilean group (JUNAEB, 2007) has added a subscale that measures resilience to the subscales of attention, conduct, and anxiety/depression problems that have been used in English language studies. We also expect to use the PSC more as a way to track functioning during pediatric or psychiatric treatment, educational or public health interventions. We have also loaded the PSC into a digital pen set up so that it can be entered and scored automatically, with results posted instantaneously into a patient’s electronic medical record in a large hospital based outpatient child psychiatry clinic.
We close this chapter by re-emphasizing that the goal of the PSC is not rapid diagnosis nor an express conduit to the use of medications. Instead, the PSC is a brief assessment of dysfunction in major areas of a child’s daily life. As an administrative or research tool, it is merely a snapshot. As a clinical measure it is merely the first step in what should be a multistage assessment procedure. Positive screens with the PSC deserve careful, considerate, intelligent follow up by trained and trustworthy clinicians who will work with parents to understand each child within the totality of a unique individual, family, community context and then hopefully find ways to provide more of the help that many parents of dysfunctional children so desperately desire.
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