Genes Expressed in the Brain Before Birth May Affect Risk of Childhood Mental Illness
Study’s findings provide additional evidence that risk for mental illness in children begins in the womb.
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The Pediatric Symptom Checklist (PSC) is a brief questionnaire that helps identify and assess changes in emotional and behavioral problems in children. The PSC covers a broad range of emotional and behavioral problems and is meant to provide an assessment of psychosocial functioning.
In addition to the original 35-item parent-reported questionnaire, there are translations into more than two dozen other languages, a youth self-report, a pictorial version and a shorter 17-item version for both parents and youth.
Psychosocial problems are relatively common, affecting about 12% of children. Such problems often go unnoticed by pediatricians, teachers and even parents and can lead to more serious problems in later life. Research shows that earlier detection and treatment can lead to better outcomes. As such, professional organizations like the American Academy of Pediatrics recommend psychosocial screening as a part of the annual physical for all children and adolescents, and the country’s largest health insurer of children requires it.
The PSC is one of the most widely used screening tools for this purpose. It is an easy-to-use tool that is broadly valid and reliable. The PSC helps meet a growing array of therapeutic, research and administrative assessment needs in a wide range of clinical, educational and public health settings.
Download Pediatric Symptom Checklist (PSC) forms below. Please review the scoring instructions section below before using the PSC in a home, school or healthcare setting. Contact us if you have any trouble with these forms.
* Translations were created for the California Department of Health Services.
You can also access the PSC and score report for free through CNS Vital Signs (requires login).
Mental Health America provides the PSC with online score reports for free:
Please note: If you are conducting research with the PSC, please send us a copy of any translations, reports, or papers you write. Our goal is to keep abreast of all research with the PSC.
The Pediatric Symptom Checklist (PSC) helps pediatricians and pediatric nurse practitioners improve the recognition of psychosocial problems in their patients. The PSC is designed to fit into the workflow of a primary care practice and can be used to alert families of psychosocial and emotional issues.
When a large number of problems are detected, the clinician should assess further and decide whether watchful waiting or additional evaluation, referral and treatment is most appropriate.
The PSC can be administered at any point in pediatric care, but most practices opt to screen yearly during well-child visits.
The PSC can be administered in a number of ways:
Each item on the PSC receives zero, one or two points, with the scores on all 35 items summed for the total score. The recommended cutoff to indicate a possible problem is based on a large national sample in the U.S., where a score of 28+ identifies about 12% of children as being at risk (Jellinek et al., 1999; Murphy et al., 2016). Other studies support different cut-off points for other patient populations (eg.,Ishizaki, et al., 2000).
In practices that administer the PSC through an EMR or platform like CHADIS (Comprehensive Health and Decision Information System), the PSC total and subscale scores are calculated automatically. In practices using paper forms, clinicians may score the PSC themselves during review, while in others the medical assistant does the scoring. Scoring procedures can be found below.
Five to 20% of scores are above the cutoff point in 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 with positive scores (Jellinek et al., 1999). This reflects the reality that the burden of psychosocial dysfunction is higher for families living in poverty and experiencing greater social stress. In some cultures, parents may not feel comfortable 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.
It is important to emphasize that the PSC is not designed to produce a diagnosis or to serve as a direct conduit to a specific treatment or medication. Instead it is meant to provide clinicians with suggestions for which patients may be at higher than average risk and with scores to compare to normative data.
Normal Range Scores
If the child’s score is within the expected normal range, you may be more confident turning your attention to other important but non-acute issues like anticipatory guidance, safety or other parental concerns.
Positive Screening Scores
If the total score or one of the sub-scale scores is in the “at-risk” range, most practices ask clinicians to devote a few extra minutes to getting a sense of why the number of problems reported is so high. Some clinicians discuss the symptoms that were marked as “often” with the parent and/or child, while others ask about major areas of daily functioning such as family, school, friends, activities and mood.
Some practices suggest that all positively screened children be offered a visit for a follow-up evaluation by a mental health professional, especially if one is readily available, while others recommend scheduling a follow-up appointment for further evaluation with the pediatrician in a week to a few months. Whatever the approach, next steps should be determined together by the parents and the clinician.
Many children who score positive may already be in therapy or have parents who do not want therapy, so it is often wisest to let parents know that a positive score indicates a high level of risk and that further assessment is probably warranted, but not mandatory.
For many children, a watchful waiting approach is also an option. This provides time to see whether problems diminish and gives parents a chance to consider next steps. Most children who screen positive on the PSC are positive again six or 12 months later. Parents who are reluctant to seek help initially may be more willing if they see that problems persist.
See the After Screening section for more information on recording scores and talking with parents.
The goal of screening with the PSC is to provide earlier intervention for children and adolescents who would benefit and prevent evolving childhood conditions from becoming more severe.
The Pediatric Symptom Checklist (PSC) helps mental health clinicians understand the types and severity of problems reported by the parents of patients or adolescent patient themselves. When administered at successive time points, the PSC can also be used to assess improvement or deterioration in functioning.
Although a high-risk score on all three subscales can provide important information on behavior or feelings that are outside of the average range, the five-item PSC internalizing sub-scale can be especially useful as a first stage screen for depression and anxiety. Scores above the cutoff (5 or higher) on this scale suggest the need for further assessment through some extra assessment time with a clinician or the administration of a depression- or anxiety-specific measure like the PHQ-9 or GAD-7.
The PSC can be administered at any point in mental health treatment, but in most service settings it is completed at intake and then every three, six or twelve months that a child remains in treatment.
The PSC can be administered in a number of ways:
It bears repeating that the PSC does not produce a diagnosis and should not serve as a direct conduit to a specific treatment or medication. Instead it provides clinicians with indications as to which patients have scores that are significantly outside the average range.
Although PSC scores vary somewhat over a few weeks to a year (Murphy, et al. 2016), the positive/negative screening scores for most patients remain the same (Hacker et al., 2009). The statistical concepts of "reliable change" and "significant change" provide parameters for judging the importance of any changes observed over time.
A change score of six or greater on the total score is considered a reliable change, and changes this large that also involve a change from risk to non-risk (or vice versa) are considered to indicate clinically significant change (Murphy, et al., 2016). On the subscales, only changes of two or more points are considered to indicate reliable change (Kamin, et al., 2015; McCarthy, et al., 2016), and only those that show a change in risk status are considered to show significant change.
Note that all considerations of change should take into who filled out the PSC. Scores are most valid when the reporter remains the same (eg, if patient’s mother fills out the PSC both times).
The Pediatric Symptom Checklist can be filled out by a parent on behalf of a child or by the child (depending on the child’s age). The PSC helps evaluate how your child is functioning at home, at school, with friends and family and during other activities in terms of mood and behavior.
It is important to understand that the PSC is not a tool for diagnosing any specific condition. PSC scores simply show how many problems are reported and whether those scores are high compared to other children. A higher PSC score often suggests a problem that can be helped, though it does not necessarily mean that your child has a disorder.
The PSC can be completed online for free. After you complete the PSC, you can download the printable report to share with your child’s pediatrician or teacher. Both the PSC score and report are anonymous and confidential. Your child’s scores from these online versions will not be shared with anyone else.
The PSC is used primarily to screen children for overall emotional and behavioral problems using a scoring system. The cut-off scores used in the screening were established using large samples of children and adolescents.
Scores that indicate risk differ depending on your child’s age:
It may be helpful to consult with an experienced clinician if your child receives a positive PSC total or subscale score. Data from past studies using the PSC indicate that two out of three children who screen positive will be correctly identified as having moderate to serious impairment in emotional or behavior functioning. Children who are "incorrectly" identified usually have at least mild impairment, although a small percentage of children turn out to have very little actually wrong with them (e.g., a child who is actually doing reasonably well, but has an overly anxious parent).
The inevitability of both false-positive and false-negative screens underscores the importance of experienced clinical judgment in interpreting PSC scores.
The standard parent-completed PSC form consists of 35 items. Each item is rated as:
The total score is calculated by adding the 35 individual scores, so the total score will be 0 to 70. If one to three items are left blank, they are ignored (and given a score of 0). If four or more items are left blank, the questionnaire is considered invalid.
The total score indicates whether a child has psychosocial impairment. A positive score on the PSC suggests the need for further evaluation by a qualified health or mental health professional. Note that both false positives and false negatives can occur.
Children ages 6-17
Children ages 3-5
Scores on elementary school-related items 5, 6, 17 and 18 are ignored. Total score is based on the 31 remaining items.
Cutoff scores for preschool and school-age children that indicate 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 overall functioning in children (Jellinek 1986; Jellinek et al. 1986; Little et al. 1994).
All PSC forms are scored the same way, but different cutoff scores have been recommended for some versions. Pediatricians whose practices serve a specific culture should begin by collecting data on several cases to ascertain the accuracy of a cut-off score of 28 for the population. If more than 25% or less than 5% of a given population screen positive, a different cut-off score should be considered.
The shorter version of the PSC (PSC-17) has also been validated and used to detect youth with psychosocial impairment, but a total cut-off score of 15 is recommended.
Subscale scores for internalizing, externalizing and attention problems can be calculated from specific items. Factor analysis of the full set of 35 items has led to the validation of three subscales for use in the identification of attentional, internalizing and externalizing problems. The clustering of these items and cutoff scores can be found below.
The youth self-report version of the PSC-17 using the same subscales has also been validated.
Children with subscores greater than or equal to 7 usually have significant impairments in attention.
Children with subscores greater than or equal to 5 usually have significant impairments with anxiety or depression.
Children with subscores greater than or equal to 7 usually have significant problems with conduct.
Validity: 68% of the children identified as PSC positive will also be identified as impaired by an experienced clinician and, conversely, 95% of the children identified as PSC negative will be identified as unimpaired (Jellinek et al. 1988). Similarly high rates of validity have been reported for the PSC-Y and several of the PSC translations.
Reliability: Test/retest reliability of the PSC ranges from r = .84 - .91. Over time, case/not case classification ranges from 83%-87% and kappa = .84 (Jellinek et al. 1988; Murphy et al. 1992).
Inter-item Analysis: Our studies (Murphy & Jellinek 1988; Murphy et al. 1996) indicate strong internal consistency of the PSC items (Cronbach alpha = .91) and highly significant (p < 0.001) correlations between individual PSC items and positive PSC screening scores.
The PSC has been endorsed by the National Quality Forum (NQF) as an outcome measure to improve the quality of care provided to children. The NQF embodies a three-part mission to:
The PSC is one of small number of NQF-endorsed child health measures and is the only one to focus exclusively on child mental health.
In several validation 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 the CGAS in both middle and lower income samples, the PSC has shown high rates of:
(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 comparable to national estimates of the prevalence of psychosocial problems (~12%) (Jellinek et al., 1988; Jellinek et al., 1991; Little et al., 1994; Murphy et al., 1992a; Murphy et al., 1996; Rauch et al., 1991).
The PSC continues to be listed as a recommended instrument because most studies that have assessed it found it to be valid and reliable with one caveat: the need for further evaluation of the specific cut-off score used to indicate dysfunction in any given population. Although two of the largest and most diverse samples studied to date (Bernal et al., 2000; Kelleher et al., 1998) found that the original recommendation appeared to be optimal (Jellinek et al., 1999), several other studies have suggested the need to determine the optimal cut-off score when new populations are studied.
Previous studies have consistently shown that the prevalence of psychosocial impairment varies considerably based on socio-demographic risk factors, and research with the PSC has paralleled many of these findings. Factors shown to increase the probability of psychosocial dysfunction include:
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) or mentally ill parent families (Jellinek et al., 1991).
Other studies have used the PSC as a marker to explore the prevalence of psychosocial problems in other pediatric settings, including:
These studies have generally confirmed a higher than average prevalence rate of psychosocial problems among poor children and under-recognition and under-referral among poor children (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, including:
These studies have generally shown that PSC positive rates are two to three times more prevalent in children with chronic conditions.
The PSC is increasingly being used to assess the impact of interventions by collecting scores after interventions. Studies have shown significant decreases in PSC scores for children who receive mental health interventions that are comparable to those found with other standardized measures (Kamin et al. 2015; McCarthy et al., 2016; Murphy et al., 2007; Murphy, 2007; Murphy et al., 2008; Murphy et al., 2011; Murphy et al., 2012).
Other studies used the PSC as an outcome measure to assess the impact of school-based mental health interventions (Murphy et al 2014; Guzman et al, 2015; Stein et al., 2003) and of school breakfast programs (Kleinman et al., 2002; Murphy et al., 1998). All of these studies showed significant improvements in functioning.
The PSC has been used as a clinical measure in large public health initiatives. Evaluations of programs provided by the Cambridge Health Alliance (Hacker, et al, 2012), the Medicaid program of the state of Massachusetts (Hacker et al 2016) and a national school mental health program in Chile (Guzman, et al 2015; Murphy et al 2014) have shown that the PSC can be implemented for routine screening in large systems and maintained for more than a decade. This research also showed that the PSC can also be combined with other elements as part of an integrated approach to child physical and behavioral health.
Research examining the factors that contribute to a change in PSC scores (Hacker, et al., 2006) found that there were statistically significant relationships between a positive change PSC score (improved functioning) and a number of factors:
The PSC is mentioned prominently in Bright Futures Mental Health (BFMH) (Jellinek et al., 2002a; Jellinek et al., 2002b), a joint project of the Maternal and Child Health Bureau and American Academy of Pediatrics that advocates 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 can be photocopied and distributed, as well as instructions for their use and recommendations for clinical practices.
The most important step for dealing with a positive PSC score is to spend a few extra minutes exploring the reason for a very high PSC score with the parent/patient. You should also discuss what, if anything, they want to do about it. Below is a script you might use.
Ask a few questions about the child's daily functioning with friends and family, at school and in activities and with his or her general mood. Going over the PSC items marked as “often” can be a productive way to focus the discussion. Then see if the parent would like to discuss further with you or do something else.
At a minimum, the note should include the four PSC scores and whether they were in the high risk or lower risk ranges.
PSC-17 Total Score (normal < 15)
PSC-17 Internalizing Subscale (normal < 5)
PSC-17 Attention Subscale (normal < 7)
PSC-17 Externalizing Subscale (normal < 7)
17 (High Risk)
4 (Lower Risk)
6 (Lower Risk)
7 (High Risk)
The narrative section of the note should include an interpretation of the four risk scores and plan for dealing with them.
For example: “This patient’s total score of 17 on the PSC-17 is outside of the average range and suggests significant problems with overall psychosocial functioning. The score of 7 on the externalizing scale is also significantly elevated and suggests a large number of problems with behavior. Discussed these scores with patient’s mother and she would like a referral to a mental health clinician for further evaluation.”
For the second time, the National Quality Forum (NQF) has endorsed Massachusetts General Hospital’s Pediatric Symptom Checklist (PSC). Details about the PSC and the three other recently endorsed measures can be found in the NQF Behavioral Health and Substance Use Fall 2017 Report.
NQF is a non-profit standards-setting organization that bases its endorsements on the judgment of panels of medical experts in collaboration with a large and diverse group of professional and community organizations through an open and transparent consensus-based process. NQF endorses measures that have evidence showing that they are valid, feasible and associated with higher quality health care. The PSC is one of only a few child mental health measures endorsed by NQF.
The PSC was created by Michael Jellinek, MD, the former chief of Child Psychiatry at Mass General and chief clinical officer of Mass General Brigham. According to Dr. Jellinek, “Although the PSC has already been used to screen several million children in statewide programs in Massachusetts and California and a in a national program in Chile, NQF’s endorsement paves the way for other states and large healthcare organizations to use the PSC to screen children and adolescents for mental health problems and to evaluate programs that serve them."
J. Michael Murphy, EdD, the PSC’s co-developer, cites the use of the PSC as a screen for adolescent depression as just one example of the way it is now being used. “With teenage suicide rates rising, depression screening has just become a performance standard for most of the country’s health plans," says Dr. Murphy. "As one of just a handful of approved measures for this kind of screening, the PSC could play an important role in getting help to more young people who need it.”
Dr. Jellinek and Dr. Murphy have published more than fifty papers validating the PSC and exploring its use in a wide variety of pediatric and mental health settings. The PSC is a 35-item questionnaire used to measure overall psychosocial functioning in children and adolescents that has been translated into more than two dozen languages, a youth self-report and a brief 17-item versions for parents and youth. All versions of the PSC are available for free in the "PSC Forms" section of this page.
The PSC was recently adopted by the California Department of Health Care Services as one of two measures required for all children and adolescents with Medicaid health insurance who receive mental health services. On July 1, 2018, assessment with the PSC or the Child and Adolescent Needs and Strengths (CANS) interview began in 33 counties with the rest of the counties to follow over the next several months. The PSC or CANS is completed by parents at intake and then every six months that a child continues to receive services. The purpose of the program is to enable providers to compare the functioning of children over time in different counties and service settings.
The PSC was selected as the primary measure of psychosocial functioning for 6-17-year-old children being seen for well-child visits (annual physicals). The PSC is completed in the waiting room on a tablet computer or at home over the internet. Scores are computed instantaneously and placed in tables that record important information, like height, weight and vital signs, where they can be easily found by pediatric clinicians and discussed with parents during the visit. These tables also display scores from previous visits to monitor changes over time.
The PSC was selected as the primary measure of psychosocial functioning for 4-17-year-old children being seen through the Mass General's Division of Child and Adolescent Psychiatry. The PSC is completed in the waiting room on a tablet computer or at home over the internet. Scores are computed instantaneously and placed in tables that record important information, including height, weight and vital signs, where they can be easily found by mental health clinicians. The PSC is administered at the beginning of treatment and then every three months that a child is in treatment, allowing clinicians to understand the severity of different types of problems and if they are improving over time.
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