MENTAL HEALTH CHILDREN Assessment http://www.nlm.nih.gov/medlinepl us/childmentalhealth.html • Screening Tools and Rating Scales [http://www2.massgeneral.org/schoolpsychiatry/sch oolpsychiatry_screeningtools.asp] • The checklists in the table below can be used to help clarify which types of mental health symptoms might be most problematic for a child or adolescent. • Use checklists does not produce a diagnosis. Rather, the checklists point toward the types of mental health disorders that may be worthwhile to consider as a cause of the child's or adolescent's emotional or behavioral difficulties. A particular “score” on a checklist does not mean that a child has a particular disorder – these checklists are only one component of an evaluation. Diagnoses should be made only by a trained clinician after a thorough evaluation. Symptoms suggestive of suicidal or harmful behaviors warrant immediate attention by a trained clinician. Screening Tools Table of Checklists for Preliminary Mental Health Screening For Ages (Years) Who Completes Checklist: Number of Items Time to Complete (Minutes) View Free Online ? Child Behavior Checklists (CBCL) DETAIL 1.5- 18 Parent, Teacher: 118 Student: 112 Clinician: 96-99 15-20 Behavioral Assessment System for Children, 2nd Ed. (BASC-2) DETAIL 2-21 8-21 Parent :134-160 Teacher:100-139 Student:139-185 Parent, Teacher: 10-20 Student: 30 Child/Adolescent Psychiatry Screen (CAPS) DETAIL 3-21 Parent: 85 15-20 Conners 3 DETAIL 3-17 Parent: 49 Teacher: 28 30 Home Situations Questionnaire (HSQ) DETAIL 4-11 Parent: 16 5 YES School Situations Questionnaire (SSQ) DETAIL 4-11 Teacher: 12 5 YES Pediatric Symptom Checklist (PSC) DETAIL 6-16 Parent: 35 5-10 YES SNAP-IV-C Rating Scale-Revised DETAIL 6-18 Parent, Teacher: 90 10 YES Beck Youth Inventories of Emotional & Social Impairment (BYI) DETAIL 7-14 Student: 5 self-reports, 20 each 5-10 per inventory YES Child Behavior Checklists (CBCL) • Behavioral Assessment System for Children, 2nd Ed. (BASC-2) • • Child Behavior Checklists (CBCL) Parent (PRF) Teacher (TRF) Youth Self-Report (YSR) Clinician (DOF) CBCL/1½-5 (Preschool) The CBCL, used for evaluating children and adolescents ages 6-18, measures problems with aggressive behavior, anxiety/depression, attention, rule-breaking behavior, social interaction, physical complaints, disordered thought, and withdrawn/depressed behavior. It is used for initial assessment and can also measure changes in behavior over time or following a treatment. The Parent Checklist is one of the most widely used parental ratings for behavioral problems and social skills in children. For evaluating children younger than age 6, the Child Behavior Checklist/1½-5 is used instead. The CBCL/1½-5, preschool form, obtains parents' ratings of 99 problem items plus descriptions of problems, disabilities, major concerns about their child, and the child's strengths. It also includes the Language Development Survey (LDS) for identifying language delays. Versions for parents, teachers, and youth each contain approximately 120 items and take 15-20 minutes to complete. The clinician form (DOF) contains 96 items and is for children and adolescents ages 5-14. Achenbach System of Empirically Based Assessment at: http://www.aseba.org/products/cbcl6-18.html Behavioral Assessment System for Children, 2nd Ed. (BASC-2) Parent (PRS) Teacher (TRS) Student (SRP) Different variations of each of these tools are available for evaluating preschoolers, children, and adolescents ages 2-21. The parent version contains 134-160 items, depending on the age of the child; the teacher version contains 100-139 items, and each takes 10-20 minutes to complete. A student report form for children and adolescents ages 8-21 contains 139-185 items and requires 30 minutes to complete. Six functional areas are assessed, including adaptability, activities of daily living, functional communication, leadership, social skills, and study skills. Clinical areas assessed include aggression, anxiety, attention problems, atypicality, conduct problems, depression, hyperactivity, learning problems, physical complaints, and withdrawal. Home Situations Questionnaire (HSQ) Parent This questionnaire, used with children and adolescents ages 4-11, supplements scales such as the Child Behavior Checklist and Conner Parent Rating Scales-Revised. It contains 16 items and takes 5 minutes to complete. The HSQ lists a number of common circumstances at home in which behavior problems are most likely to arise. Parents can indicate the severity of behavior problems for each situation. • The HSQ is available online in PDF format at: http://www2.jabsom.hawaii.edu/dop/wpcontent/uploads/2007/12/home-situationsquestionnaire.doc • • School Situations Questionnaire (SSQ) Teacher This companion to the HSQ helps teachers identify the types of situations, from a total of 12 items, in which the child's behavioral problem is apparent at school. Like the HSQ, the SSQ is used with children ages 4-11 and takes 5 minutes to complete. The scale counts the frequency of problem occurrence as well as the severity of each problem area. The questionnaire is available online in PDF format at: http://www.drjenna.net/checklists/adhd_bx _cl/school_sitn_quest.pdf Child/Adolescent Psychiatry Screen (CAPS) • Child/Adolescent Psychiatry Screen (CAPS) Parent • This 85-item screen is organized around symptoms of common psychiatric disorders in children and adolescents ages 3-21. • It allows parents to prioritize symptoms rapidly to discuss with their clinicians. • This screen is useful for identifying target symptoms or disorders, but it is not useful for monitoring the effects of treatment. It takes 15-20 minutes to complete. • • • • The Child/Adolescent Psychiatry Screen (CAPS) http://www2.massgeneral.org/schoolpsychiatry/CAPS.htm I. How to Use the Child/Adolescent Psychiatry Screen (CAPS) If you suspect your child has a mental health condition and are not sure what symptoms are most troublesome, the Child/Adolescent Psychiatry Screen can provide an initial indicator of areas for further investigation. This is only a preliminary screening tool. Do not assume that a particular “score” means a child has a particular disorder; many people have symptoms like those described in this screening tool, but do not have a “disorder.” Diagnoses should be made only by a trained clinician after a thorough assessment. Symptoms suggestive of suicidal or harmful behaviors warrant immediate attention by a trained clinician. Answer all items in the checklist , using the appropriate column to indicate the frequency of each symptom. Examine the columns to determine if certain clusters of items have more “Moderate” or “Severe” responses. Don’t panic: having a high (or low) number of moderate or severe responses in any section does NOT mean that your child has this disorder. It just means that these symptoms should be discussed with a trained clinician familiar with these disorders so that you can make sense of these symptoms (and determine the best course of action to address them). Symptoms are arranged in sections/clusters to help identify areas for discussion with a trained clinician: • • • • • • • • • Items 1-7 Anxiety Item 8 Panic Disorder Item 9 Phobia Item 10-11 Obsessive-Compulsive Disorder (OCD) Item 12 Post-Traumatic Stress (PTSD) Item 13 Generalized Anxiety Disorder Item 14 Enuresis (bed-wetting) / Encopresis (fecal soiling) Items 15-16 Tics (vocal and/or motor) Items 17-31 Attention Deficit/Hyperactivity Disorder (ADD/ADHD) • • • • • • • • • Items 32-38 Mania/Bipolar Disorder Items 39-46 Depression Items 47-49 Substance Abuse / Dependence Items 50-53 Anorexia / Bulimia Items 54-64 Antisocial Disorder Items 65-70 Oppositional Defiant (ODD) Disorder Items 71-72 Hallucinations or Delusions Items 73-74 Learning Disability Items 75-85 Autistic Spectrum (including Asperger’s) • • • Use the results for a focused conversation with your child’s primary care clinician, mental health clinician, or with school staff about options to improve your child’s mental health. If particular sections receive mostly moderate and severe answers, show and describe these to your clinician. At that time, it may be useful to show and describe the “Past” column, since some symptoms tend to predict certain other symptoms or clarify other factors to consider. Consider obtaining additional screening tools and rating scales for more detailed assessment. Many of these are described and/or accessible from www.schoolpsychiatry.org. II. Child/Adolescent Psychiatry Screen (CAPS) Child’s Name:______________________________________ Date of Birth :_________________ Male _____ Female _____ Form Completed By:_________________________________ Relationship to Child:________________________________ For each item below, check the one category that best describes your child during the past 6 months. None = the child never or very rarely exhibits this behavior. Mild = the child exhibits this behavior approximately once per week, and few others notice or complain about this behavior. Moderate = the child exhibits this behavior at least three times per week, and others notice or comment on this behavior. Severe = the child exhibits this behavior almost daily, and multiple others complain about this behavior. Past = the child used to have significant problems with this behavior, but not during the past 6 months. • • • • • • • • • • • • • 1. Has difficulty separating from parents* (* = or major caregiver/guardian) _____None _____None _____Mild _____Moderate _____Severe ____Past 2. Worries excessively about losing or harm occurring to parents* _____None _____None _____Mild _____Moderate _____Severe ____Past 3. Worries about being separated from parent* (getting lost or kidnapped) _____None _____None _____Mild _____Moderate _____Severe ____Past 4. Resists going to school or elsewhere because of fears of separation _____None _____None _____Mild _____Moderate _____Severe ____Past 5. Resists being alone or without parents* _____None _____None _____Mild _____Moderate _____Severe ____Past 6. Has difficulty going to sleep without parent nearby _____None _____None _____Mild _____Moderate _____Severe ____Past 7. Physical complaints (headache, stomach ache, nausea) when anticipating separation _____None _____None _____Mild _____Moderate _____Severe ____Past 8. Has discrete periods of intense fear that peak within 10 minutes _____None _____None _____Mild _____Moderate _____Severe ____Past 9. Has excessive, unreasonable fear of a specific object or situation _____None _____None _____Mild _____Moderate _____Severe ____Past 10. Has recurrent thoughts that cause marked distress (e.g., fears germs) _____None _____None _____Mild _____Moderate _____Severe ____Past 11. Driven to perform repetitive behaviors (e.g., handwashing, doing things 3 times) _____None _____None _____Mild _____Moderate _____Severe ____Past 12. Has recurrent, distressing recollections of past difficult or painful events _____None _____None _____Mild _____Moderate _____Severe ____Past 13. Worries excessively about multiple things (e.g., school, family, health, etc.) _____None _____None _____Mild _____Moderate _____Severe ____Past • • • • • • • • 14. Goes to the bathroom at inappropriate times or places _____None _____None _____Mild _____Moderate _____Severe 15. Makes noises, and is often unaware of them _____None _____None _____Mild _____Moderate _____Severe 16. Makes repetitive, sudden, nonrhythmic movements _____None _____None _____Mild _____Moderate _____Severe 17. Fails to pay close attention to details or makes careless mistakes _____None _____None _____Mild _____Moderate _____Severe 18. Has difficulty sustaining attention during play or school activities _____None _____None _____Mild _____Moderate _____Severe 19. Does not seem to listen when spoken to directly _____None _____None _____Mild _____Moderate _____Severe 20. Does not follow through on instructions; fails to finish schoolwork/chores _____None _____None _____Mild _____Moderate _____Severe 21. Has difficulty organizing tasks and activities _____None _____None _____Mild _____Moderate _____Severe ____Past ____Past ____Past ____Past ____Past ____Past ____Past ____Past • • • • • • • • • • • • • • 22. Loses things necessary for tasks are activities (toys, pencils, etc.) _____None _____None _____Mild _____Moderate _____Severe ____Past 23. Is easily distracted easily by irrelevant stimuli _____None _____None _____Mild _____Moderate _____Severe ____Past 24. Is forgetful in daily activities _____None _____None _____Mild _____Moderate _____Severe ____Past 25. Is fidgety or squirms in seat _____None _____None _____Mild _____Moderate _____Severe ____Past 26. Has difficulty remaining seated _____None _____None _____Mild _____Moderate _____Severe ____Past 27. Runs or climbs excessively; is restless _____None _____None _____Mild _____Moderate _____Severe ____Past 28. Talks excessively _____None _____None _____Mild _____Moderate _____Severe ____Past 29. Blurts out answers before questions have been completed _____None _____None _____Mild _____Moderate _____Severe ____Past 30. Has difficulty waiting turn _____None _____None _____Mild _____Moderate _____Severe ____Past 31. Interrupts or intrude on others _____None _____None _____Mild _____Moderate _____Severe ____Past 32. Episodes of unusually elevated or irritable mood _____None _____None _____Mild _____Moderate _____Severe ____Past 33. During this episode, grandiosity or markedly inflated self-esteem (Superhero ) _____None _____None _____Mild _____Moderate _____Severe ____Past 34. During this episode, is more talkative than usual/seems pressured to keep talking _____None _____None _____Mild _____Moderate _____Severe ____Past _____Moderate _____Severe ____Past • • • • • • • 35. During this episode, races from thought to thought _____None _____None _____Mild _____Moderate _____Severe ____Past 36. During this episode, is very distractible _____None _____None _____Mild _____Moderate _____Severe ____Past 37. During this episode, excessively involved in things (too religious, hypersexual) _____None _____None _____Mild _____Moderate _____Severe ____Past 38. During this episode, dangerous involvement in pleasurable activity (spending, sex) _____None _____None _____Mild _____Moderate _____Severe ____Past 39. Depressed or irritable mood most of the day, most days for at least 1 week _____None _____None _____Mild _____Moderate _____Severe ____Past 40. Loss of interest in previously enjoyable activities _____None _____None _____Mild _____Moderate _____Severe ____Past 41. Notable change in appetite (not when dieting or trying to gain weight) _____None _____None _____Mild • • • • • • • • • • • • 42. Difficulty falling or staying asleep, or sleeping excessively through the day _____None _____None _____Mild _____Moderate _____Severe ____Past 43. Others notice child is sluggish or agitated most of the time _____None _____None _____Mild _____Moderate _____Severe ____Past 44. Loss of energy nearly every day _____None _____None _____Mild _____Moderate _____Severe ____Past 45. Feelings of worthlessness or inappropriate guilt nearly every day _____None _____None _____Mild _____Moderate _____Severe ____Past 46. Thinks about dying or wouldn’t care if died _____None _____None _____Mild _____Moderate _____Severe ____Past 47. Smokes cigarettes, drinks alcohol, OR abuses drugs (Circle all that apply) _____None _____None _____Mild _____Moderate _____Severe ____Past 48. Has bad things happen when under the influence of substances _____None _____None _____Mild _____Moderate _____Severe ____Past 49. Has made unsuccessful efforts to stop using a substance _____None _____None _____Mild _____Moderate _____Severe ____Past 50. Is excessively worried about gaining weight, even though underweight _____None _____None _____Mild _____Moderate _____Severe ____Past 51. If female, has stopped having menstrual cycles (after regularly having) _____None _____None _____Mild _____Moderate _____Severe ____Past 52. Thinks he/she is fat, even though not overweight (pulls skin and claims is fat, etc.) _____None _____None _____Mild _____Moderate _____Severe ____Past 53. Engages in binging and purging (eats excessively, then vomits or uses laxatives) _____None _____None _____Mild _____Moderate _____Severe ____Past • • • • • • • • 54. Bullies, threatens, or intimidates others _____None _____None _____Mild _____Moderate 55. Initiates physical fights _____None _____None _____Mild _____Moderate 56. Uses weapons that could harm others _____None _____None _____Mild _____Moderate 57. Has been physically cruel to animals _____None _____None _____Mild _____Moderate 58. Has shoplifted or stolen items _____None _____None _____Mild _____Moderate 59. Has deliberately set fires _____None _____None _____Mild _____Moderate 60. Has deliberately destroyed others’ property _____None _____None _____Mild _____Moderate 61. Lies to obtain goods or to avoid obligations _____None _____None _____Mild _____Moderate _____Severe ____Past _____Severe ____Past _____Severe ____Past _____Severe ____Past _____Severe ____Past _____Severe ____Past _____Severe ____Past _____Severe ____Past • • • • • • • • • • 62. Stays out at night despite parental prohibitions _____None _____None _____Mild _____Moderate _____Severe 63. Has run away from home overnight on at least two occasions _____None _____None _____Mild _____Moderate _____Severe 64. Is truant from school _____None _____None _____Mild _____Moderate _____Severe 65. Loses temper _____None _____None _____Mild _____Moderate _____Severe 66. Actively defies or refuses to comply with adult rules _____None _____None _____Mild _____Moderate _____Severe 67. Deliberately annoys others _____None _____None _____Mild _____Moderate _____Severe 68. Blames others for his/her mistakes or misbehavior _____None _____None _____Mild _____Moderate _____Severe 69. Easily annoyed by others _____None _____None _____Mild _____Moderate _____Severe 70. Is spiteful or vindictive _____None _____None _____Mild _____Moderate _____Severe _____Mild _____Moderate _____Severe ____Past ____Past ____Past ____Past ____Past ____Past ____Past ____Past ____Past ____Past • • • • • • • • • • • 71. Has unusual thoughts that others cannot understand or believe _____None _____None _____Mild _____Moderate _____Severe ____Past 72. Hears voices speaking to him/her that others don’t hear _____None _____None _____Mild _____Moderate _____Severe ____Past 73. Does poorly at sports or games requiring physical coordination skills _____None _____None _____Mild _____Moderate _____Severe ____Past 74. Has difficulty at school with: reading, writing, math, spelling (Circle all that apply) _____None _____None _____Mild _____Moderate _____Severe ____Past 75. Had delayed speech or has limited language now _____None _____None _____Mild _____Moderate _____Severe ____Past 76. Avoids eye contact during conversations _____None _____None _____Mild _____Moderate _____Severe ____Past 77. Does not follow when others point to objects _____None _____None _____Mild _____Moderate _____Severe ____Past 78. Shows little interest in others; emotionally out of sync with others _____None _____None _____Mild _____Moderate _____Severe ____Past 79. Difficulty starting, stopping conversation; continues talking after others lose interest _____None _____None _____Mild _____Moderate _____Severe ____Past 80. Uses unusual phrases, possibly over and over (speaks Disney or movie lines) _____None _____None _____Mild _____Moderate _____Severe ____Past 81. Does not engage in make-believe play; plays more alone than with others _____None _____None • • • • • • 82. Unusual preoccupations with objects or unusual routines (lines up 100’s of cars, etc.) _____None _____Mild _____Moderate _____Severe ____Past 83. Difficulty with transitions; may be inflexible about adhering to routines or rules _____None _____Mild _____Moderate _____Severe ____Past 84. Shows unusual physical mannerisms (hand-flapping, shrieks, objects in mouth, etc.) _____None _____Mild _____Moderate _____Severe ____Past 85. Unusual preoccupations (schedules, own alphabet, weather reports, etc.) _____None _____Mild _____Moderate _____Severe ____Past Thank you for answering each of these items. Please list any other symptoms that concern you: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ © Copyright 2004 Jeff Q. Bostic: This screen may be freely used by individuals, clinicians, or schools, but may not be used for profit or for proprietary purposes • Pediatric Symptom Checklist (PSC) Parent The PSC can be completed by parents and contains 35 items for children and adolescents ages 6-16. It is available free in English and Spanish. Translations into Creole, Mandarin Chinese, and Swahili also exist. The PSC is designed to alert clinicians early to difficulties in functioning that may indicate current or potential psychosocial problems, so that early intervention might be provided. It is used only as a screening tool and not to make a formal diagnosis or measure treatment interventions. The PSC takes 5-10 minutes to complete. • It is available free at: http://psc.partners.org/psc_order.htm • • (Adapted from Jellinek, M. "Approach to the Behavior Problems of Children and Adolescents." In T.A. Stern, J.B. Herman, P.L. Slavin (Eds.) The MGH Guide to Psychiatry in Primary Care. 1998. New York: McGraw-Hill: 437-443). Why screen for psychosocial problems? – – – – Studies indicate that less than 30 percent of children with substantial dysfunction are recognized by primary care clinicians. Nationally, referral rates of children seen by pediatricians to mental health services range from 1 to 4 percent. Often recognition depends on parental complaint or school report of overt behavioral problems; early recognition, prevention, and less overt dysfunction (such as secondary and childhood depression, or family factors such as divorce) are much less likely to be addressed. Children with chronic disease are about twice as likely to have a psychosocial disorder (those suffering from epilepsy are at highest risk). Psychosocial functioning also has an impact on medical compliance and is associated with higher utilization of primary care services. Children who have major difficulties in one area of functioning often demonstrate symptoms and difficulties in other areas of daily functioning. For example, if they are having school difficulties secondary to attentiondeficit/hyperactivity disorder (ADHD), symptoms such as motoric activity or impulsivity will be evident at home and may interfere with other activities. Even less overt disorders such as learning disabilities or difficulties in peer relationships will often manifest as depressed mood at home, tension with siblings, or low self-esteem. Accidents, a leading cause of death in children and adolescents, are often secondary consequences of psychosocial stressors. Fires, falls from windows, drowning, and motor vehicle accidents are all more likely in the context of psychosocial dysfunction. http://psc.partners.org/psc_order.htm • How can screening for psychosocial problems help children? – – Screening enables clinicians to recognize problems – quickly – and to provide help, preferably at an early and effective point. Screening tests are not designed to yield diagnoses or label children. For example, rather than review symptoms of diabetes in every child, a urine screening test helps the primary care clinician determine which children need further evaluation. Similarly, psychosocial screening is a starting point for further questions and assessment. A key component for determining appropriate treatment, as prescribed by the DSM-IV (Diagnostic and Statistical Manual of Mental Disorder. Fourth Edition) and the DSM-IV-PC (Diagnostic and Statistical Manual of Mental Disorder. Fourth Edition. Primary Care Version), is the extent of impairment or severity. Some presentations, such as psychosis or a serious suicide attempt, are clearly severe and will need to be referred for possible hospitalization. Other conditions, however, such as depression or ADHD, can vary widely in severity and in milder cases will be managed in primary care settings, some with support or changes in school program; others with psychotropic medications and more comprehensive treatment programs. Early recognition, at a point before damage to self-esteem, is both prognostically better for the child and economically better for the child’s family and for those funding services. • • Psychosocial Problems and Screening Childhood psychosocial dysfunction, considered a "new morbidity" twenty-five years ago, has become widelyacknowledged as the most common, chronic condition of children and adolescents.1, 2 Epidemiologic studies report that 12-25% of all American school-age children and 13% of preschoolers have an emotional and/or behavioral disorder.3-8 The rates of psychosocial impairment are higher in risk groups such as low income and/or single parent households. With the advent of managed and especially capitated health care systems,10 primary care providers assume an even greater "gatekeeping" responsibility to identify, manage and refer children with emotional and/or behavioral disorders.11 Yet, recent studies estimate that only about 50% of these children are identified by their primary care physicians and that once identified, only a fraction of these children receive appropriate mental health treatment.9, 12-15 • • A number of studies16-19 have documented an increasing prevalence of behavioral and emotional problems in the U.S. and other countries in children and adults. Despite the growing burden of psychosocial morbidity, pediatricians still do not receive adequate training concerning psychosocial problems,20 are hesitant to attach potentially deleterious labels to children,13 do not have time during office visits to address psychosocial needs, and may have limited access to mental health referral networks.15 Recent efforts such as the American Board of Pediatrics increasing ambulatory and behavioral training requirements, publications such as Bright Futures,21 and the Diagnostic and Statistical Manual for Primary Care22 may help to increase awareness of psychosocial morbidity over the long-term, but as of now primary care pediatricians still struggle to provide psychosocial services.2, 21-22 The move to managed care approaches in medicine and the increasing focus on productivity and profitability has created an additional pressure for pediatric clinicians to limit attention on psychosocial problems. One way to counterbalance this pressure is to use a parent-completed screening questionnaire as part of routine primary care visits23 to facilitate recognition and referral of psychosocial problems. The Pediatric Symptom Checklist (PSC) was developed for this purpose. The PSC is a one-page questionnaire listing a broad range of children's emotional and behavioral problems that reflects parents' impressions of their children's psychosocial functioning. Cutoff scores for pre-school and school-age children indicating 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 children's overall functioning. 24-25 • • In a number of validity studies, PSC case classifications agreed with case classifications on the Children's Behavior Checklist (CBCL), clinicians' 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.26-30 When compared to Children's Global Assessment Scale scores (CGAS) in both middle and lower income samples, the PSC has shown high rates of overall agreement (79%;92%), sensitivity (95%;88%) and specificity (68%;100%).24-27 Studies using the PSC have found prevalence rates of psychosocial impairment in middle class or general settings (~12%) that are quite comparable to national estimates of psychosocial problems. 25-30 More recently, efforts to develop specific subscales of the PSC for use in identification of attentional, internalizing (depression/anxiety), and behavior problems31 and to develop both child32 and teacher-report versions of the PSC are well along. Previous studies using a variety of measures have consistently shown that the prevalence of psychosocial impairment varies considerably based on a number of sociodemographic risk factors, and research with the PSC has paralleled many of these findings. For example, low socioeconomic status,33 living with a single parent,34 parental mental illness,35-36 family discord ,37 the child's temperamental characteristics, and male sex 37-38 have all been shown to increase the probability of psychosocial dysfunction. 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,27,39 single-parent,27 and/or mentally ill parents.28 • Research currently in progress suggests that routine psychosocial screening with the PSC is associated with increased mental health referrals, decreasing child symptom scores, and increased parental satisfaction. Other studies are looking at the costs of screening and possible cost offsets in pediatric medical costs after children are screened and treated. • • • • • • • • The following information relates to the psychometric properties of the PSC: Instructions for Scoring: The PSC consists of 35-items that are rated as never, sometimes, or often present and scored 0, 1, and 2, respectively. Item scores are summed and the total score is recoded into a dichotomous variable indicating psychosocial impairment. For children aged six through sixteen, the cut-off score is 28 or higher. For four and five year-old children, the PSC cut-off is 24 or higher (Little et al, 1994; Pagano et al, 1996). Items that are left blank by parents are simply ignored (score = 0). If four or more items are left blank, the questionnaire is considered invalid. How to Interpret the PSC: A positive score on the PSC suggests the need for further evaluation by a qualified health (M.D., R.N.) or mental health (Ph.D, LICSW) professional. Both false positives and false negatives occur, and only an experienced clinician should interpret a positive PSC score as anything other than a suggestion that further evaluation may be helpful. Data from past studies using the PSC indicate that 2 out of 3 children who screen positive on the PSC will be correctly identified as having moderate to serious impairment in psychosocial functioning. The one child "incorrectly" identified usually has at least mild impairment, although a small percentage of children turn out to have very little actually wrong with them (e.g., an adequately functioning child of an overly anxious parent). Data on PSC-negative screens indicate 95% accuracy, which, although statistically adequate, still means that 1 out of 20 children rated as functioning adequately may actually be impaired. The inevitability of both false-positive and false-negative screens underscores the importance of experienced clinical judgment in interpreting PSC scores. Therefore, it is especially important for parents or other lay people who administer the form to consult with a licensed professional if their child receives a PSC-positive score. Validity: Using a Receiver Operating Characteristic Curve, Jellinek, Murphy, Robinson, et al (1988) found that a PSC cutoff score of 28 has a specificity of 0.68 and a sensitivity of 0.95 when compared to clinicians’ ratings of children’s psychosocial dysfunction. In other words, 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. Reliability: Test-re-test reliability of the PSC ranges from r = .84 - .91. Over time, case/not case classification ranges from 83% 87%. (Jellinek & Murphy, 1988; Murphy et al, 1992). Inter-item Analysis: Our studies (Murphy & Jellinek, 1985; Murphy, Ichinose, Hicks, et al, 1996) also indicate strong (Cronbach alpha = .91) internal consistency of the PSC items and highly significant (p < 0.0001) correlations between individual PSC items and positive PSC screening scores. Qualifications for Use of the PSC: The training required may differ according to the ways in which the data are to be used. Professional school (e.g., medicine or nursing) or graduate training in psychology of at least the Master’s degree level would ordinarily be expected. However, no amount of prior training can substitute for professional maturity, a thorough knowledge of clinical research methodology, and supervised training in working with parents and children. There are no special qualifications for scoring. SNAP-IV-C Rating Scale-Revised • Parent Teacher Although devised (by Swanson, Nolan and Pelham) primarily for ADHD, the SNAP contains 90 items that can be completed by parents, teachers, or other caregivers for use by a healthcare provider in a more general assessment. The SNAP-IV-R takes 10 minutes to complete and is used with children and adolescents ages 618. Criteria for ADHD and Oppositional Defiant Disorder are included. In addition, the SNAP-IV-C contains 10 items about classroom symptoms of inattention, hyperactivity, and impulsivity. Additional items assess Conduct Disorder, Intermittent Explosive Disorder, Tourette's Disorder, Stereotypic Movement Disorder, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Narcolepsy, Manic Episode, Major Depressive Episode, and Dysthymic Disorder. • Available free online at: www.ADHD.net or at http://www.add-pediatrics.com/add/snapiv.html. • Beck Youth Inventories of Emotional & Social Impairment (BYI) Beck Youth Inventories of Emotional and Social Impairment (BYI) Student These five self-report assessments for children and adolescents 7-14 years old can be used separately or in any combination to assess a youth's experiences of depression, anxiety, anger, disruptive behavior, and self-concept. Each inventory contains 20 statements that take approximately 5-10 minutes to complete. • Available for purchase at: http://harcourtassessment.com/haiweb/Cultures/enUS/default.htm. Psychotherapies Children And Adolescents • http://www.aacap.org/cs/root/facts_for_families/psychothera pies_for_children_and_adolescents Psychotherapy is a form of psychiatric treatment that involves therapeutic conversations and interactions between a therapist and a child or family. It can help children and families understand and resolve problems, modify behavior, and make positive changes in their lives. There are several types of psychotherapy that involve different approaches, techniques and interventions. At times, a combination of different psychotherapy approaches may be helpful. In some cases a combination of medication with psychotherapy may be more effective. Different types of psychotherapy: • Cognitive Behavior Therapy (CBT) helps improve a child's moods, anxiety and behavior by examining confused or distorted patterns of thinking. CBT therapists teach children that thoughts cause feelings and moods which can influence behavior. During CBT, a child learns to identify harmful thought patterns. The therapist then helps the child replace this thinking with thoughts that result in more appropriate feelings and behaviors. Research shows that CBT can be effective in treating a variety fo conditions, including depression and anxiety. • Dialectical Behavior Therapy (DBT) can be used to treat older adolescents who have chronic suicidal feelings/thoughts, engage in intentionally self-harmful beaviors or have Borderline Personality Disorder. DBT emphasizes taking responsibility for one's problems and helps the person examine how they deal with conflict and intense negative emotions. This often involves a combination of group and individual sessions. • Family Therapy focuses on helping the family function in more positive and constructive ways by exploring patterns of communication and providing support and education. Family therapy sessions can include the child or adolescent along with parents, siblings, and grandparents. Couples therapy is a specific type of family therapy that focuses on a couple's communication and interactions (e.g. parents having marital problems). • Group Therapy is a form of psychotherapy where there are multiple patients led by one or more therapists. It uses the power of group dynamics and peer interactions to increase understanding of mental illness and/or improve social skills. There are many different types of group therapy (e.g. psychodynamic, social skills, substance abuse, multi-family, parent support, etc.). • Interpersonal Therapy (IPT) is a brief treatment specifically developed and tested for depression, but also used to treat a variety of other clinical conditions. IPT therapists focus on how interpersonal events affect an individual's emotional state. Individual difficulties are framed in interpersonal terms, and then problematic relationships are addressed • Play Therapy involves the use of toys, blocks, dolls, puppets, drawings and games to help the child recognize, identify, and verbalize feelings. The psychotherapist observes how the child uses play materials and identifies themes or patterns to understand the child's problems. Through a combination of talk and play the child has an opportunity to better understand and manage their conflicts, feelings, and behavior. • Psychodynamic Psychotherapy emphasizes understanding the issues that motivate and influence a child's behavior, thoughts, and feelings. It can help identify a child's typical behavior patterns, defenses, and responses to inner conflicts and struggles. Psychoanalysis is a specialized, more intensive form of psychodynamic psychotherapy which usually involved several sessions per week. Psychodynamic psychotherapies are based on the assumption that a child's behavior and feelings will improve once the inner struggles are brought to light. • Psychotherapy is not a quick fix or an easy answer. It is a complex and rich process that, over time, can reduce symptoms, provide insight, and improve a child or adolescent's functioning and quality of life. • At times, a combination of different psychotherapy approaches may be helpful. In some cases a combination of medication with psychotherapy may be more effective. Child and adolescent psychiatrists are trained in different forms of psychotherapy and, if indicated, are able to combine these forms of treatment with medications to alleviate the child or adolescent's emotional and/or behavioral problems.
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