Journal of Pediatric Psychology, Vol. 28, No. 5, 2003, pp. 315-321
© 2003 Society of Pediatric Psychology
Clinical Case Study: Pediatric Residents' Discussions of and Interventions for Children's Behavioral and Emotional Problems
1 University of Mississippi Medical Center, 2 Louisiana State University
All correspondence should be sent to Heather Applegate, University of Mississippi Medical Center, Department of Psychiatry and Human Behavior, 2500 N. State Street, Jackson, Mississippi 39216–4505. E-mail: hbrapplegate{at}yahoo.com.
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Abstract |
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Objective To examine the effects of a screening instrument and parent handouts on pediatric residents' discussions of and interventions for children's behavioral and emotional problems. Method Four pediatric residents and 52 parent-child dyads attending an ambulatory pediatric primary care clinic participated in the study. We used a multiple baseline design across residents. We assessed the effect of the interventions by measuring nine target behaviors of the pediatric residents. Results After being trained to use the screening instrument, residents increased the number and variety of questions they asked regarding behavioral and emotional issues. Residents' attempts at intervention showed small but consistent increases when handouts on behavior management procedures were made available for distribution to parents. Conclusions The use of a screening instrument in pediatric primary care shows promise for increasing discussions between residents and parents about children's behavioral and emotional issues. Further research should examine strategies to improve pediatric residents' attempts at intervention for behavioral and emotional problems in children.
Key words: pediatric primary care; child behavior problems; screening.
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Introduction |
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In November 2001, the American Academy of Pediatrics renewed its commitment to the identification and treatment of children's behavioral and emotional disorders. Behavioral and emotional disorders, first recognized as the "hidden morbidity" in primary care pediatrics more than 20 years ago (Haggerty, Roghmann, & Bless, 1975
; Kelleher & Wolraich,
1995), are now the leading cause of disability in children and
adolescents (Costello et al.,
1988; Costello, Edelbrock,
& Costello, 1988; Kelleher
& Wolraich, 1995). Estimates of child behavioral problems in
pediatric settings range from 11% to 22% (e.g.,
Costello et al., 1988), whereas
rates of physician recognition of these problems range from 5% to 9%
(Costello et al., 1988;
Lavigne et al., 1993).
Some researchers have suggested that physicians' use of a
behavioral screening instrument might increase identification of children's
behavioral and emotional problems (Jellinek
& Murphy, 1990), partly because, before entering the exam
room, the physician would have specific behavioral information that can serve
as a starting point for discussion
(Stancin & Palermo, 1997).
To date, only one study has examined physicians' use of a behavioral screening
instrument on recognition of and intervention for children's behavioral and
emotional problems (i.e., Murphy, Arnett,
Bishop, Jellinek, & Reede, 1992). Murphy et al. demonstrated
that routine implementation of a behavioral screening instrument increased the
rate of mental health referrals from less than 2% to greater than 10%.
However, physicians' verbalizations in the exam room (e.g., asking questions
or commenting) and attempts at interventions other than mental health
referrals were not examined.
The purpose of this case study was to evaluate the effects of a brief screening instrument (Pediatric Symptom Checklist [PSC]) and parent handouts on pediatric residents' discussions of and interventions for behavioral/emotional problems in school-age children. We hypothesized that use of the PSC would increase residents' discussions of behavioral/emotional problems in children. However, we were uncertain whether the screening instrument would increase residents' interventions because the instrument itself does not provide recommendations concerning treatment. For this reason, parent handouts addressing specific behavioral and emotional issues were made available to the resident as an adjunct to traditional treatment options (e.g., mental health referral). A second purpose of this case study was to assess parent satisfaction with the clinic visit as it related to the use of the PSC and parent handouts.
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Method |
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Design
A multiple baseline design across subjects (Barlow & Hersen, 1984
) was
used to examine the effects of a screening instrument (PSC condition) and a
screening instrument plus parent handouts (PSC + handouts condition) on
residents' discussions and interventions regarding behavioral and emotional
issues.
Participants
Four pediatric residents and 52 parent-child dyads attending an ambulatory
pediatric clinic participated. The residents were men in their first year of
residency. Three of the residents were in their late twenties and one (G. F.)
was in his early forties. All four of the residents were given the first week
of the 4-week rotation to acclimate to the clinic routine before they were
invited to participate in the study.
Parent-child dyads included children ages 6 to 16 attending well-child visits or visits for minor, acute illnesses (e.g., otitis media). Children attending the clinic for evaluation of behavior problems were not included. Of the 56 eligible parent-child dyads, 52 participated (two dyads declined to participate because of the audiotaping and two refused for personal reasons). The mean age of the children was 10.37 (SD = 3.53). Of the 52 children, 18 were boys, and 48 were African Americans (4 Caucasians). The clinic population consists primarily of low-income African American families.
Response Definitions
Nine target behaviors (definitions and examples available from the first
author) were identified by a review of the literature. The nine behaviors (in
italics) were categorized as either total behavioral discussions (included
initial questions about behavioral/emotional issues, followup questions
about behavioral/emotional issues, and comments about
behavioral/emotional issues) or interventions (included offered the
parent advice, reassurance, education, behavioral handout, mental health
referral, or prescription).
Materials
Pediatric Symptom Checklist. The PSC is a 35-item parent-completed
questionnaire that evaluates the behavioral/emotional functioning of children
ages 6 to 16 (Jellinek et al.,
1988; Murphy & Jellinek,
1985; Murphy, Jellinek, &
Milinsky, 1989). A cutoff score of 28 has consistently
differentiated between children with behavioral/emotional problems and
typically developing children, with a sensitivity of .95, a specificity of
.68, and a kappa of .60 (Jellinek et al.,
1988; Murphy, Jellinek, Lamb,
& Fenton, 1986). Parent Satisfaction Questionnaire
(PSQ). The PSQ is a 20-item measure of parental satisfaction with their
child's health care (Finney et al.,
1990), modified from the Medical Interview Satisfaction Scale
(MISS; Wolf, Putnam, James, & Stiles,
1978). Items are rated on a Likert-type scale ranging from
"strongly disagree" to "strongly agree." The range of
possible scores is 20 (extreme dissatisfaction) to 100 (extreme
satisfaction).
Parent Handouts. Five separate handouts were developed describing common behavioral and emotional problems in children and corresponding parental interventions. Handouts were designed to match clusters of symptoms from the PSC as closely as possible.
Procedures
The study was approved by the participating medical center's institutional
review board, and written consent was obtained from the participants. Parents
were informed that their children's visit with the resident would be
audio-taped. Parents completed the PSC in the waiting room and the PSQ in the
exam room after their child's visit was complete. Parents and residents were
informed that the purpose of the study was to investigate parent-physician
communication during pediatric visits.
Baseline
Baseline was in effect for four patient visits (i.e., four audiotaped
sessions with each parent-child dyad) for the first resident in each pair
(i.e., J. G. and K. E.) and for six patient visits for the second resident in
each pair (B. S. and G. F.). The residents did not have access to the
parent-completed PSC during the baseline condition.
PSC Condition
After baseline, the residents were trained individually using a
standardized protocol developed for the purpose of this study.1 The
residents were taught how to use and score the PSC, and it was placed on the
medical chart before the resident saw the patient. The resident was
responsible for scoring the PSC and deciding how to use the information. The
PSC condition was in effect for four clinic visits for each resident.
PSC + Handouts Condition
After the PSC condition, the residents were trained individually on the
importance of intervention, and behavioral handouts were provided that the
resident could distribute to parents. The behavioral handouts were stored in
slots along a wall in the nurses' station next to other types of patient
brochures. The resident was responsible for deciding how and when to use the
handouts. The PSC + handouts condition was in effect for four clinic visits
for each resident.
Data Collection and Interobserver Agreement
Data were collected using a frequency count of the nine target behaviors. A
second rater blind to the residents' condition independently recorded the
target behaviors from 30% (n = 16) of the audiotapes. Interobserver
agreement, calculated by dividing the number of agreements by the number of
agreements plus disagreements and multiplying by 100, ranged from 87% to 100%,
with a mean score of 94%.
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Results |
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The total number of behavioral discussions and interventions is presented in Figure 1A, 1B. As shown, behavioral discussions increased from baseline to the treatment conditions for each of the residents.
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The total number of interventions demonstrated no appreciable difference for any of the residents from baseline to the PSC condition, but showed a small, consistent increase from the PSC condition to the PSC + handouts condition. However, offering the parent a behavioral handout was not available to the residents in the baseline or PSC condition. When excluded from the analysis, there was no appreciable difference across the three conditions for any of the residents.
Exploratory analysis of the relationship between the PSC score and the combined number of behavioral discussions and interventions was examined. This analysis was conducted by excluding parent-child dyads in the baseline condition and collapsing the data across residents (n = 32). A partial correlation coefficient controlling for child age failed to yield a significant relationship between the PSC score and the number of behavioral discussions and interventions (r = .21, ns). Also, of the 13 children in the PSC or PSC + handouts condition with PSC scores greater than the clinical cutoff of 28, only two (15%) patients received referrals for follow-up evaluations.
Parent satisfaction was also examined. Figure 2A, 2B presents PSQ scores for each condition. Visual analysis indicates that PSQ scores for two residents (K. E. and J. G.) were slightly lower during the PSC + handouts condition when compared to baseline and the PSC condition, whereas the other two residents (G. F and B. S.) showed more stability of PSQ scores by condition.
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An exploratory analysis was conducted to examine PSQ scores by condition collapsing across residents. The mean PSQ score was 87.75 (SD = 6.89) for the baseline condition, 91.13 (SD = 6.58) for the PSC condition, and 84.13 (SD = 8.82) for the PSC + handouts condition. A one-way analysis of variance (ANOVA) revealed a significant difference between groups, F(2, 51) = 3.73, p < .05. Post-hoc analysis using the Student-Newman-Kuels procedure revealed that PSQ scores for the PSC + handouts condition were significantly lower than those for the PSC condition.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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This case study provides preliminary evidence that use of a screening instrument in pediatric ambulatory clinics may increase discussions about behavioral/emotional issues between residents and parents. These results are important in light of the American Academy of Pediatrics' (2001
) renewed commitment to
psychosocial aspects of pediatric care. As mentioned previously, increasing
discussions about behavioral and emotional issues is a necessary first step in
building effective strategies for identifying psychologically distressed
children. Our results suggest that use of a screening instrument may increase both the number and variety of behavioral discussions. For example, although G. F. consistently initiated behavioral discussions during baseline, his variety of questions was limited. For five of the six patients in his baseline phase, he limited his behavioral questions to "How's school going?" and "How are things at home?" During the experimental conditions, he continued to ask questions about school and home but also inquired about a variety of other behaviors endorsed by the parent on the PSC.
This case study also demonstrated a small but consistent increase in interventions during the PSC + handouts condition, although this trend disappeared when the specific intervention of offered the parent a behavioral handout was removed from the analysis. Several possible explanations may explain this finding. First, none of the children in this study attended the clinic for evaluation of behavioral problems; therefore, the residents may have decided that intervention was not warranted for some of these children and deliberately chose not to intervene. Second, the intervention may not have been effective because the training was not as intensive as needed in order to effect a change in resident behavior. Third, the study included first-year residents with limited experience working with children and families, which may have affected their ability or willingness to attempt behavioral interventions with parents and children.
One potentially troubling finding of this case study was the failure to
obtain an association between the PSC score and the total number of behavioral
discussions or interventions, suggesting that the residents may not have used
the PSC for its intended purpose of identifying children in need of more
intensive screening or intervention
(Murphy et al., 1989).
Research examining physicians' ability to use a screening instrument to
accurately identify and intervene with children in psychological distress will
clarify this issue.
Another issue that must be explored is parent satisfaction. In this study, two of the residents (K. E. and J. G.) showed decreases in parent satisfaction during the PSC + handouts condition. Because of the small sample size, these findings are not indicative of behavioral screening/intervention decreasing parent satisfaction, but they are nonetheless troubling. Ideally, parent satisfaction would be high when the provider screens for behavioral problems and provides intervention as necessary. Future studies examining behavioral screening by pediatric providers should carefully evaluate the effects of the intervention on parent satisfaction.
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Notes |
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1 All training materials are available upon request from the first author. Training materials included written tests given to the residents after each intervention to increase treatment integrity. All residents scored 92% or higher on the written tests.
Received March 25, 2002; revision received June 3, 2002; accepted July 17, 2002
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