Using the PSC
Screening presents an opportunity for pediatric primary care clinicians to improve their recognition of which 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. The guidelines and philosophy of the PSC list are congruent with the philosophy behind screening and the evolving concept of a “medical home” for children well described on the AAP website (http://pediatrics.aappublications.org/content/110/1/184.full.pdf). 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.
How to start screening
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 a visit. Some practices screen during every visit. Because the brief time allocated for sick visits may make even a small amount of additional paperwork for screening more difficult to complete, many practices opt to give out the screen only during well-child visits. Another common practice is handing out a brief note with the PSC describing the purpose of the screening and making it clear that 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 others, 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.
Some practices now co-locate 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. 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.
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 procedures can be found in the Scoring the PSC 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 and social stress. In some cultures parents may not feel comfortable in acknowledging or emphasizing psychosocial issues and, as such, 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 cut-off score of 17 is recommended (Ishizaki et al., 2002); while in European samples, a cut-off of 24 is recommended (Herzog & Thun-Hohenstein, 2007). In a Mexican-American sample, a lower cutoff of 12 was shown to be most sensitive (Jutte et al., 2003). All of this suggests that pediatricians whose practice serves a distinct culture should begin by collecting data on a number of cases to ascertain the accuracy of a cut-off score of 28 for their population. By definition, in 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).
It is important to emphasize that the PSC is not designed to be diagnostic or 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 is so high. Some practices 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, while others recommend scheduling a follow up appointment in 3 to 6 months for further evaluation. 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. 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 a positive score indicates a 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.
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 his/her 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.
In the same way, 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, 17, or even 12 can be indicative of serious dysfunction. 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 Manic Depressive illness can function normally in many respects and 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 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 & 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 Reynolds Children’s Manifest Anxiety Scale (Reynolds & Richman, 1985) may be more accurate or appropriate.
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 I, Agreement between child and parent on individual symptoms.” Journal of Abnormal Child Psychiatry 10:307-24.
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)." The Journal of the Japan Pediatric Society 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, 995–998.
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 (1978). “What I think and feel: A revised measure if children’s manifest anxiety.” Journal of Abnormal Child Psychiatry 6: 271-280.