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Implementing the PSC
USING THE PEDIATRIC SYMPTOM CHECKLIST IN YOUR OFFICE
Goal: For pediatric primary care clinicians to improve their recognition of which 3 to 16 year old patients have psychosocial dysfunction in a major area of their daily life at home, in school, with friends, in activities, and/or in their moods or self-esteem. Recognition should lead to further assessment by the clinician, future follow-up to determine trajectory of dysfunction, and/or referral for more comprehensive evaluation and treatment.
How to start: Decide when you want to hand out the PSC. For most practices that are new to screening, the logical time would be at the start of all well-child visits. Some practices screen during every visit…but the brief time allocated for sick visits makes even a small amount of additional paperwork for screening more difficult to complete. Some practices hand out a brief note with the PSC describing the purpose of the screening, making it clear that the screening is voluntary and like all other medical information, confidential.
In many practices, the PSC screening form is sent to families along with other forms in a packet in the mail prior to the visit. In other practices, front desk staff members ask parents to complete the form when they check in and then attach the completed form to the chart for the clinician to review at the start of the visit.
Clinical approach to the meaning of positive and negative scores
In most practices, clinicians score the form themselves at the same time that they review it. The simple math can be done in just a few seconds while the clinician scans the form to get a sense of which questions are checked “often”. An alternative is to have a receptionist or medical assistant do the scoring and hand the pediatrician the scored form. Scoring is reviewed on another section of this website.
Scores above the cut point on the PSC occur in 5-20% of most populations. This range reflects the fact that economic and cultural factors impact psychosocial functioning and reporting. For example, poverty is a major stressor that increases the percentage of children scoring positive. The higher percentage screened positive reflects the reality that the burden of psychosocial dysfunction is higher for families living in poverty. In some cultures parents may not to acknowledge or emphasize psychosocial issues as much and the entire bell shaped distribution of scores and rate of positives may be shifted toward lower scores.
The cut-off score we recommend is based on large national samples in the United States where a score of 28+ identifies about 12% of children as being at risk (Jellinek et al., 1999). In Japan, a cutoff score of 17 is recommended (Ishizaki et al., 2002) and in European samples a cutoff of 24 is recommended (Herzog and Thun-Hohenstein, 2007). In a Mexican-American sample a cutoff of 12 was recommended (Jutte et al., 2003). Pediatricians whose practice serves a distinct culture should begin by collecting data on a number of cases to ascertain the accuracy of a cutoff score of 28 for their population. By definition in a representative samples of US children, PSC scores of 28 or higher occur in just 5-12% of the population and usually indicate problems in multiple areas of functioning and usually one or more psychiatric diagnoses as well. All of the cross cultural work to date confirms that a score of 28 or higher is associated with very poor functioning, although, as implied above, in other cultural groups a score of 28 may produce many false negatives (e.g., it may miss children who need services but whose scores fall below the cutoff because their problems or their parents’ reporting of them are less frequent).
If the PSC score is below the cutoff point and within the expected normal range, pediatricians may be more confident that during this visit they can turn their attention to other important but non-acute issues like anticipatory guidance, safety, or other parental concerns.
It is important to emphasize that the PSC is not designed to be diagnostic or to serve as a conduit to a specific treatment or medication. Some pediatricians take the next step themselves after a positive screening and discuss with the family those symptoms marked as “often”. Others will ask parents of all positively screened children several questions about each of the child’s major areas of daily functioning – family, school, friends, activities and mood to get a sense of why the number of problems reported may be so high. Some practices may suggest that all positively screened children be seen for a brief follow up evaluation by a mental health professional, especially if one is readily available on site or nearby. Whatever the practice, the choice of specific next steps should be jointly decided by the parent and the clinician. Many children who score positive are already in some form of therapy or have parents who do not want therapy. For this reason it is often wisest to let parents know that the score probably indicates a very high level of dysfunction and that further assessment is probably warranted—either right then or at another visit. But a wait-and-see approach can also be sound clinical decision. Parents can be given some time to consider next steps or a follow-up visit can be offered. Most PSC positive children are positive again six or twelve months later and parents who are reluctant to seek help initially may be more willing to do so if the problems persist.
Limitations: The PSC does not make a specific psychiatric diagnosis (although most children who are positive will after evaluation be determined to have a psychiatric diagnosis). A positive PSC score indicates that the pediatrician should spend part of her/his office visit with the child and family to assess psychosocial functioning, confirm the positive screening, and then do a further evaluation themselves or refer for a mental health evaluation.
Caveats: The absence of a positive screening score does not mean that there are no problems or that the problems that are reported are not significant. As noted above, in some cultural groups scores of 24 or 17 or even 12 can be indicative of serious dysfunction. And even in traditional US groups, children could still be functioning well because they are especially resilient, a problem is too early in its evolution, or an issue such as domestic violence is being kept secret. Some children with well managed problems like OCD or even Manic Depressive illness can function normally in many respects and can obtain PSC scores within the normal range. The PSC helps the pediatrician recognize many issues by reflecting on the parent’s view of the child symptoms and functioning, but no questionnaire can alert the pediatrician to every issue or every secret. The PSC is designed to warn clinicians early of difficulties in functioning that may indicate current or potential (i.e., future) psychosocial problems. In other words, use of the PSC may make it possible for clinicians to intervene earlier and thus to prevent some evolving childhood conditions from becoming more severe. One of the most commonly used PSC forms also contains an additional question that asks simply for the parent’s perception of whether the child has a problem for which he/she needs help. Depending on the resources of the practice, this question can also be used as an opportunity to spend more time with a parent who has questions about a child or who wants advice or support. This question can also be used to validate or confirm the screening score used in that practice.
Although parents have been shown to be the most reliable reporters of their children’s psychosocial and behavioral problems, some mood disorders, particularly depression and anxiety in adolescents, may be more reliably identified by the children themselves (Herjanic and Reich, 1982). When problems like these are suspected, the youth self-report version of the PSC (Pagano et al., 1996; Gall et al., 2000) or a specific disorder screen like the Children’s Depression Inventory (Kovacs, 1985) or the Revised Children’s Manifest Anxiety Scale (Reynolds and Richman, 1985) may be more accurate or appropriate.
Context: The PSC is designed to fit into the work flow of a primary care practice and to alert families that the pediatrician is interested in psychosocial and emotional issues. Many offices use implementation of psychosocial and behavioral screening to review broader areas of communication with families. For example, does the practice have an introductory letter that explains the pediatrician’s policies and philosophy? In psychosocial areas, such an introductory letter may alert parents to the practice’s screening procedures, best books or AAP websites or developmental and psychosocial information, policies related to confidentiality, etc. As a part of this review, pediatricians might want to think through what information they have available in the office on key developmental and psychosocial topics. Some practices now co-locate some mental health services directly on site by having a mental health professional see referred patients in the pediatric office setting, possibly starting during evening hours when both parents might be available. Some larger practices, knowing the prevalence of Attention Deficit Disorder, depression (postpartum and in early childhood), or divorce, have used their waiting rooms after hours to offer support groups, led by a mental health clinician, so that parents can support and learn from each other during stressful times.
The guidelines and philosophy of the Pediatric Symptom Checklist are congruent with the evolving concept of a “medical home” for children well described on the AAP website.
References:
Gall, G., M. E. Pagano, M. S. Desmond, J. M. Perrin and J. M. Murphy (2000). Utility of psychosocial screening at a school-based health center. J Sch Health 70(7): 292-8.
Herjanic, B. and W. Reich (1982). Development of a structured psychiatric interview for children: agreement between child and parent on individual symptoms. Journal of Abnormal Child Psychology 10(3): 307-24.
Herzog, S. and L. Thun-Hohenstein (2007). The predictive value of the pediatric symptom checklist in 5-year-old Austrian children. European Journal of Pediatrics.
Ishizaki, T., Y. Fukai and Y. Kobayashi (2002). Utility of the Japanese version of the Pediatric Symptom Checklist to screen children with psychosocial problems in the primary and junior high schools and juvenile guidance and consultation offices in Japan (in Japanese). Journal of Japanese Society of Psychosomatic Pediatrics 10: 119-127.
Jellinek, M. S., J. M. Murphy, M. Little, M. E. Pagano, D. M. Comer and K. J. Kelleher (1999). Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: a national feasibility study. Archives of Pediatrics & Adolescent Medicine 153(3): 254-60.
Jutte, D. P., A. Burgos, F. Mendoza, C. B. Ford and L. C. Huffman (2003). Use of the Pediatric Symptom Checklist in a low-income, Mexican American population. Arch Pediatr Adolesc Med 157(12): 1169-76.
Kovacs, M. (1985). The Children's Depression, Inventory (CDI). Psychopharmacology Bulletin 21(4): 995-8.
Pagano, M., J. M. Murphy, M. Pedersen, D. Mosbacher, J. Crist-Whitzel, P. Jordan, C. Rodas and M. Jellinek (1996). Screening for psychosocial problems in 4-5-year-olds during routine EPSDT examinations: Validity and reliability in a Mexican-American sample. Clinical Pediatrics 35(3): 139-146.
Reynolds, C. R. and B. O. Richman (1985). Revised Children's Manifest Anxiety Scale (RCMAS).