Family Practice Vol. 21, No. 3, 261-265
Family Practice Vol. 21, No. 3 © Oxford University Press 2004, all rights reserved.
Use of information about maternal distress and negative life events to facilitate identification of psychosocial problems in children
Department of Psychology, Kent State University, Kent, OH 44242, USA
E-mail: bwildman{at}kent.edu
Received 24 February 2003; Revised 2 October 2003; Accepted 7 January 2004.
Yerkey TM and Wildman BG. Use of information about maternal distress and negative life events to facilitate identification of psychosocial problems in children. Family Practice 2004; 21: 261–265.
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Abstract |
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Background. Despite the availability of effective screening measures, primary care physicians fail to identify and manage many children with psychosocial problems. Physicians often have information about significant negative events in a child's life. The present study evaluated the potential utility of using information about negative life events to facilitate physician identification of children with psychosocial problems.
Methods. Negative life events, maternal distress and child psychosocial functioning measures were completed by 185 mothers of children, aged 4–12 years. Family physicians provided data about the children's psychosocial functioning.
Results. Mothers identified 15.1% (n = 28) of the children as having psychosocial problems. Physicians correctly identified 21% (n = 6) of these at-risk children. Physician use of negative life events would have led to the identification of 39.2% (n = 11) at-risk children. Information about maternal distress and negative life events would have resulted in an additional 18% (n = 5) of children identified by the physicians. Information about maternal distress alone would have resulted in an identification rate of 53.5% (n = 15).
Conclusions. Using information about negative events in a child's life, physicians could improve their rate of identification of children with psychosocial problems. Children who have had more than two negative events in their lives are at increased risk for psychosocial problems.
Keywords. Life events, maternal distress, physician identification, psychosocial problems.
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Introduction |
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Epidemiological studies indicate that between 15 and 20% of children experience psychosocial problems, yet <2% of children are seen by mental health professionals in a given year.1–3 Most children in the USA with psychosocial problems are managed by their primary care physicians [(PCPs) i.e. paediatricians or family physicians], yet PCPs identify only a small proportion of children with psychosocial problems. This discrepancy between the base rates for psychosocial problems and identification of children with these problems continues to exist despite the availability of empirically supported methods for identifying these children (e.g. Pediatric Symptom Checklist).4 Standardized instruments to assess psychosocial functioning are rarely used in clinical practice.
One of the primary obstacles to identification faced in the primary care setting is lack of time in actual contact with children. An average encounter with a PCP lasts 
10–12 min with each patient and their parent, and parents typically disclose and question more about physical well-being than about psychosocial issues, even though parents admit to having questions about psychosocial problems.1,5
Previous research has found that PCPs are likely to identify and manage psychosocial problems in children when parents disclose concerns about their child's behaviour or emotions.6 However, parents often fail to disclose concerns, even when the child has a psychosocial problem. Since children are unlikely to display psychosocial problems within the context of a primary care office and mothers often fail to disclose psychosocial concerns that they may have, PCPs must find ways to identify psychosocial problems without using valuable time that could be used to address other health needs. Simply asking parents a global question about their concerns often does not result in disclosure of psychosocial concerns. Physicians would be significantly aided in identifying children with psychosocial problems if they could use information they are already likely to have, or that is quickly and easily obtained during typical encounters with children and their parents. Research addressing correlates of child psychopathology has indicated that two factors associated with psychosocial problems in children that are often known to PCPs are maternal psychological distress and stressful life events, such as divorce, death or birth of a sibling.
Physicians may be able to use information about maternal distress and/or negative life events (NLEs), which is often gathered during routine assessment, as an indication that further assessment for psychosocial problems is warranted. The purpose of the present study was to evaluate the potential utility of using the information that PCPs are likely to have about negative events in their patients' lives as well as their perception of maternal distress, to help them identify child psychosocial problems. We hypothesized that children who experienced NLEs would be more likely to have psychosocial problems. We further hypothesized that maternal distress would also be related to child psychosocial problems.
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Methods |
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Participants
Of the 227 mothers who agreed to participate, 185 provided complete questionnaires. The participants were 185 mothers who accompanied their child, aged 4–12 years, for a well-child or acute care appointment with their child's PCP. The mothers ranged in age from 24 to 53 years with a mean age of 36.8 years; 145 were married and 40 were single parents. The majority of the participants were Caucasian (97.8%), and (2.2%) were African-American. Type of medical insurance and education level were used as proxies for socio-economic status. Most of the participants (91.0%) reported that they had private insurance, 4.4% reported they had Medicare coverage and 3% reported having no medical insurance. No information was available for 2.0% of the participants. The median education level of the mothers was some college. The children were between the ages of 5 and 12 years with a mean age of 7.6 years; 51% were male and 49% female.
The eight physicians from the three family medical practices provided information about all of the children in the sample. The participating practices were located in working class suburbs of Akron, Ohio.
Instruments
Pediatric Symptom Checklist (PSC)4.
Child psychosocial functioning was assessed using the PSC. The PSC is a well-standardized 35-item inventory that is completed by a parent and assesses child psychosocial functioning.7 The PSC was constructed for screening children in primary care paediatric settings. Parents assign a score of 0, 1 or 2 to each behaviour. A score of 
28 is con-sidered indicative of clinically significant psychosocial problems.4 Using the 28 cut-off and comparing with ratings by clinicians, the PSC was found to have a sensitivity of 0.95, indicating a 5% false-negative rate, and a specificity of 0.68, indicating a 32% false-positive rate.8 These authors argued that while raising the cut-off score could reduce the number of false positives, it would reduce the sensitivity, which would result in a lack of attention to children most in need. Research has indicated that even if one assumes that some of the children identified by the PSC have subsyndromal problems, these problems persist over time and interfere with functioning at school, with peers and at home.9,10
Beck Depression Inventory (BDI)11. The BDI was used as a measure of the mother's psychosocial distress. It was designed as a measure of non-specific negative affect, or the syndrome of depression (rather than the diagnostic entity), and can be said to indicate an individual's level of distress or dysphoria.12 The BDI contains 21 items on which responses to each item are rated from 0 to 3. Kendall et al.13 suggested that total scores of 10–20 were indicative of dysphoria, and scores of >20 were more likely to indicate the presence of diagnostic clinical depression. The internal consistency of the BDI is good, with a mean coefficient alpha of 0.81 in non-psychiatric samples.12 The BDI correlates strongly and signifi- cantly with other measures of depression and with clinical ratings for both psychiatric and non-psychiatric samples.12
Coddington Life Events Inventory: Modified (LEI)14. The LEI is a 30-item questionnaire that is completed by parents. It lists events that may have happened to the child in the past 12 months and includes a broad and representative sample of life events such as birth of a sibling, divorce of parents and beginning school. The LEI was modified in the present study to allow the mother to evaluate whether the impact of each event was positive, negative or neutral for her child.
Demographic questionnaire. This questionnaire obtained information about mother's age, ethnicity, education, medical insurance and marital status as well as her child's age and sex.
Physician checklist.
The Physician checklist was based on categories developed by the World Health Organization, and was adapted from previous research done in primary care settings.6 The question that was used to indicate physician identification of a psychosocial problem in the current study was: "Are you concerned the child might have any type of psychosocial or developmental problem?" The Physician checklist required 1 min to complete.
Procedure
Undergraduate research assistants used a standard protocol approved by the Kent State University Human Subjects Review Board to recruit mothers visiting the physician with their child. Mothers were provided with verbal and written descriptions of the study and written consent was obtained. Mothers who could not read the questionnaires and those who could not speak English were excluded from the study. The physicians completed the Physician checklist for each child within 24 h of seeing the child.
Statistical methods
Relative risk and chi-square analyses were used to determine the utility of using NLEs and BDI scores to identify children at risk for psychosocial problems.
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Results |
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The mean PSC score was 16.4, with 15.1% (n = 28) of the children scoring in the clinical range for psychosocial problems (PSC > 27). The physicians identified six of these 28 children (21.4%) as having psychosocial problems. The mean score on the BDI was 6.2 and 46 mothers (20.9%) obtained BDI scores in the distressed range (BDI > 9). The mean total number of life events reported by the mothers was 2.4 with an SD of 2.7. These life event totals were then broken down into three categories: neutral (mean = 0.8, SD = 1.3), positive (mean = 1.2, SD = 1.5) and negative (mean = 0.5, SD = 1.1). The NLEs most frequently endorsed by the mothers appear in Table 1. NLEs were used in all analyses because they had a higher correlation with the PSC than did either positive, neutral or total life events. Participants who reported
2 NLEs were 1 SD above the mean for reported NLEs and were classified in the present study as having high NLEs.
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Correlation coefficients were computed to determine the relationship among the variables. As Table 2 shows, all variables, other than positive life events, were significantly correlated with each other.
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Relationship between negative life events, maternal distress and child psychosocial problems
Relative risk (RR) analyses were performed to determine the relative risk of the mother reporting a high PSC score when both significant maternal distress (BDI > 9) and NLEs >1 were reported, and when either significant maternal distress or high NLEs were reported. An elevated PSC was 4.5 times more likely when the mother was distressed than when she was not [chi-square = 22.49; P < 0.0001; RR = 4.52, 95% confidence interval (CI), 2.36 < RR < 8.68]. As Table 3 indicates, among the 28 children with clinically elevated PSC scores, mothers' BDI scores were elevated 53.6% of the time (15/28 participants). However, when children did not have clinically elevated PSC scores, mothers' BDI scores were elevated only 14.5% of the time (23/136 participants), resulting in a sensitivity of .54 and specificity of 0.83.
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The RR of having a high PSC was 5.11 times higher when
2 NLEs were reported than when <2 NLEs were reported (chi-square = 26.00; P < 0.0001; RR = 5.11, 95% CI 2.79 < RR < 9.39). Among the 21 children who had experienced 2 NLEs, 11 (52.38%) had clinically elevated PSC scores. As Table 4 shows, among the children who had not experienced 2 NLEs, 10.24% (17/149) had elevated PSC scores, resulting in a sensitivity of 0.39 and a specificity of 0.93.
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The RR of having a high PSC was 8.89 times greater when both the BDI and NLEs were elevated than when neither were elevated (chi-square = 52.94; P < .0001; RR = 8.89, 95% CI, 5.52 < RR < 14.31). Among children with both
2 NLEs and mothers with elevated BDI scores, 90.90% (10/11) had clinically elevated PSC scores, resulting in a sensitivity of 0.35 and a specificity of 0.99. The one child who did not have an elevated PSC score when both the BDI was elevated and 2 NLEs were present had a PSC score of 24, which suggests that this child was likely to be experiencing subsyndromal psychosocial problems. If the physicians had used information about mothers' distress and/or NLEs, identification of children with psychosocial problems would have improved to 57.1% (n = 16). If physicians had used only the information about NLEs to identify children with psychosocial problems, physician identification would have been 39.2% (n = 11/28) and if only the information about maternal distress had been used by physicians to identify children with psychosocial problems, physician identification would have been 53.5% (n = 15). The children who were identified when NLEs were employed in the identification process were also identified when maternal distress was used for identification.
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Discussion |
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The results of the present study indicate that if physicians use psychosocial information that they often obtain in their interviews with patients, namely information about NLEs in a child's life and perception of maternal distress, they could improve their rate of identification of children with psychosocial problems to >50% in comparison with the
20% whom they routinely identified. Information about NLEs is easily, and often routinely, obtained from parents. Formal assessment of maternal distress is often more time consuming and may be seen as excessively intrusive by some mothers. Obtaining information about NLEs in the child's life may be more comfortable for paediatric providers, as well as for some mothers, than specifically assessing maternal distress. Sharing information about events in their child's life should seem natural in the context of a paediatric visit. The use of data that are correlated with maternal distress, such as NLEs, may help bring psychosocial issues to the attention of the PCP. Previous research suggests that whenever parents report psychosocial problems in their children, the parent's and family's, as well as the child's, psychosocial functioning should be evaluated.15 NLEs are specific, but not as sensitive as standardized screening measures for psychosocial problems, such as the PSC.4 However, in light of the fact that physicians do not use the PSC, but do talk to their patients, questions about NLEs may lead to increases in the number of children with psychosocial problems who are identified and treated.
PCPs are in an excellent position due to their on-going contact with children to identify and intervene for psychosocial problems relatively early. Although some children with multiple NLEs and/or distressed parents may adapt well and not demonstrate psychosocial problems, further questioning by a PCP is likely to show interest to the parent, and is likely to result in identification of many children who would otherwise have been overlooked. In addition, children who have experienced multiple negative stressful life events and/or have parents who are experiencing personal distress tend to be at risk for developing psychosocial problems. Early identification and intervention with these children is likely to prevent impairment in their functioning in school, with peers and at home.9,10,16–20
The present study highlights the importance of attending to warning signs that psychosocial problems may be present. Many mothers fail to report psychosocial concerns about their child to their child's physician.6 If physicians are going to improve their rate of identification and treatment of children with psychosocial problems, then physicians need to utilize all means of identification available to them within their time and practice constraints. Further, the availability of evidence- based parenting interventions that improve child behaviour, decrease parental stress and are appropriate for use in primary care, such as the Positive Parenting Program (Triple-P), would allow PCPs to intervene effectively for the problems that they identify.16–20
Observation of psychosocial problems is unlikely in the typical office encounter, and use of pencil and paper screening measures, such as the PSC, has not been widely incorporated into routine office practice. Approaches to identification that seem most useful are those that do not require significant changes in office practice and capitalize on information that is already available to the physician. NLEs and evidence of maternal distress fit this profile. If physicians used this information, they could almost triple their rate of identification.
The results of this study indicate that physicians should ask specific questions about NLEs that may have occurred in their patients' lives. Asking such questions could lead to more information about potential psychosocial problems that patients are facing and could substantially improve identification.
As with all research, the present study has limitations that must be considered when interpreting the results. Earlier studies employing the Physician checklist found higher rates of physician identification than was found in the present study.21 In the past, data were provided primarily by family practice residents working in a training clinic. The physicians in the present study had completed their training and had been in practice for a number of years. In addition, the patients in the present study were of higher socio-economic status, as determined by a higher proportion of patients with private insurance, than were participants in previous studies.
The findings of the present study indicate that physicians can improve their rates of identification of children with psychosocial problems by using information about stressful life events. Information about stressful events, such as parental divorce, illness or death of a family member is often known to primary care providers. In addition, this information is readily accessible during brief encounters with the mother and child, and is often part of routine assessment. The current data indicate that if a child has experienced two NLEs, additional assessment of psychosocial functioning, such as assessment of maternal distress or specific questions about child behaviour, is warranted. This assessment could involve further specific question about the psychosocial functioning of the child and family, use of standardized measures such as the BDI or PSC, scheduling a follow-up appointment to assess psychosocial functioning, referral to a mental health professional, or intervention by the PCP. Further, if a mother presents with psychosocial distress, assessment of child functioning is also warranted.
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