I. Description of the problem. Regular surveillance and periodic screening for behavioral problems in pediatric settings is important because effective child intervention techniques result in a more positive impact on behavioral problems if children are identified and referred for appropriate services early. Studies in primary care settings have shown that close to 25% of children have significant behavioral problems, yet pediatric clinicians fail to identify many of them, and refer successfully only a minority of children to mental health professionals for further evaluation and treatment.
Effective monitoring consists of regular surveillance, characterized by repeated observations over time, and periodic screening using validated instruments at regular intervals. In the context of routine pediatric care, surveillance of a child’s emotional and behavioral health status should be a part of every health supervision visit, and screening is recommended at specified visits. Further evaluation may be performed by pediatric clinicians or may be deferred to a mental health consultant.
II. Selection and utilization of behavioral screening instruments. Most surveillance and screening methods available for behavioral problems rely on caregiver report, often via questionnaires or rating scales. Standardized surveillance and screening instruments allow comparisons to normative standards, analogous to showing parents a child’s weight on a standardized growth chart. Most can be administered in advance of clinical encounters and scored easily by clerical staff, and thus are efficient and inexpensive methods for collecting information. As electronic methods of administering and scoring such questionnaires become more widespread and accepted, the efficiency and utility of their use will increase further. Rating scales can be an excellent way to collect and compare the opinions of multiple observers as well, especially teachers.
The use of standardized screening instruments and other systematic procedures have been shown to increase identification of child behavior problems in primary care settings. Monitoring of behavioral/emotional status using standardized instruments should occur within the context of a clinical evaluation of every child, combining information from the checklist with the history, direct observation, physical examination, and diagnostic tests. Formal screening procedures should be psychometrically sound, acceptable to parents, accurate, cost effective, and fit into the practice setting.
If a concern is identified on regular surveillance (or as part of a periodic schedule), an appropriate next step would be a “first-stage” screening instrument. These are generally brief parent questionnaires, standardized to identify children in need of further evaluation. Additional clarity will be obtained from a “second-stage” screening instrument, administered by the pediatrician or a mental health consultant, and often available in formats for completion by multiple observers.
A. Selection of instruments depends on the particular goals of screening but should take into consideration the following factors:
Ages of the children to be screened
Informants (parent, teacher, and child)
Characteristics of available screening tools (sensitivity, specificity, acceptability, efficiency, and cost)
Impact of procedures on practice (e.g., training and supervision of staff responsible for implementation and maintenance of screening procedures)
Cost and reimbursement issues
Procedures for further evaluation and interventions of children who screen positive
Mental health resources available
Possible adverse consequences of screening
Table 11-1 contains a list of some behavioral screening instruments that have been recommended because of their acceptable psychometric characteristics and utility in primary care settings. Comparative studies are just emerging, which will assist with decisions about selecting one method over others.
Table 11-1. Selected behavioral surveillance and screening methods
Title of instrument
Screening focus
Informant*
Ages (years)
Time (minutes)
Comments
Surveillance
Bright Futures Tool and Resource Kit
http://brightfutures.aap.org
Forms for different screening purposes
Parent
0-21+
Varies by form
Tool kit of various forms and screens to accompany Bright Futures recommendations for developmental and behavioral surveillance and screening.
Parents’ Evaluation of Developmental Status (PEDS)
www.pedstest.com
Developmental and behavioral concerns
Parent
0-8
5
Questions prompt parents to observe and describe concerns.
First-Stage Screening
Ages and Stages Questionnaire— Social Emotional (SE)
http://www.agesandstages.com
Social and emotional behavior
Parent
0.5-5
10-15
Eight questionnaires for different ages. Can be used alone or in conjunction with ASQ-3. English and Spanish.
Brief Infant-Toddler Social-Emotional Assessment Scale (BITSEA)
http://www.pearsonassessments.com
Emotional competencies and problems of infants and toddlers
Parent
1-4
15
Developmentally and clinically sensitive.
Pediatric Symptom Checklist (PSC)
http://www2.massgeneral.org/allpsych/psc/psc home.htm
General psychological functioning
Parent
4-16
<5
Specifically designed for use in pediatric settings to screen for psychosocial dysfunction. Cutoffs, but no standard scores. Can be downloaded and used free of charge.
Strengths and Difficulties Questionnaire (SDQ)
http://www.sdqinfo.com
General behavioral functioning
Parent, teacher, adolescents
3-16
5
Twenty-five items of positive and negative attributes. Scores interpretable as normal, borderline or abnormal. Free in public domain. Available in many languages.
Second-stage screening
Behavior Assessment System for Children (BASC-2)
http://psychcorp.pearsonassessments.com
Multidimensional behavioral screening and assessment
Parent, teacher, and child self-report formats
2-22
10-20
Broad-based measure of pathology. Provides a profile of internalizing and externalizing problems, other problems (atypicality, withdrawal); and adaptive skills. Standard T-scores provide norm-based comparisons by age and gender. Validity check included. Norms available by age and gender. Computer scoring recommended.
Child Behavior Checklists (CBCL, TRF, C-TRF, YSR)
http://www.aseba.org/
Multidimensional behavioral screening and assessment
Parent, teacher, and child self-report formats
1½-Adult
20
Broad-based measure of pathology. Provides a profile of internalizing and externalizing problems. Standard T-scores provide norm-based comparisons by age and gender, with DSM-compatible scales. Spanish versions available. Computer scoring or Internet administration recommended.
Infant-Toddler Social-Emotional Assessment Scale (ITSEA)
http://www.pearsonassessments.com
Emotional competencies and problems of infants and toddlers
Parent
1-4
30
Extension of BITSEA. 17 subscales address four domains; focus on strengths and weaknesses. Developmentally and clinically sensitive. English and Spanish. Computer scoring available.
* Parent = parent or a primary caregiver.
Portions adapted from Perrin E, Stancin T. A continuing dilemma: whether and how to screen for concerns about children’s behavior in primary care settings. Pediatr Rev 23: 264-282, 2002 and from Stancin T, Aylward GP. Screening instruments: behavioral and developmental. In Ollendick T, Schroeder C (eds), Encyclopedia of Pediatric and Child Psychology. New York: Kluwer Academic/Plenum publishers, 2003, pp. 574-577. Test author information available upon request and at most test Web sites.
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Behavioral Screening
Behavioral Screening
Terry Stancin
Ellen C. Perrin
