Journal of Pediatric Psychology Advance Access published online on December 8, 2008
Journal of Pediatric Psychology, doi:10.1093/jpepsy/jsn128
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Mental Health Services for Preschool Children in Primary Care: A Survey of Maternal Attitudes and Beliefs*
1Department of Clinical and Health Psychology and 2Department of Pediatrics University of Florida
All correspondence concerning this article should be addressed to Michelle D. Harwood, University of Miami, Department of Pediatrics; Clinical Research Building, 12th floor—no. 1212; 1120 NW 14th St., Miami, FL 33136, USA. E-mail: mharwood{at}med.miami.edu
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Abstract |
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Objective This study examined maternal attitudes and practices that may prevent preschoolers from receiving needed mental health services. Methods Mothers of 110 children ages 3–6 completed a survey of maternal attitudes and practices and the Eyberg Child Behavior Inventory (ECBI). Results Mothers wanted pediatrician assistance with child behavior concerns. Mothers of children with elevated ECBI scores reported most often discussing disruptive behaviors with their pediatrician, and preferred clinician-provided services, whereas mothers of children with normal range ECBI scores most often discussed developmental issues with the pediatrician and preferred parenting help from handouts and books. Mothers reported receiving clinician-provided services almost never. Conclusions Mothers were open to psychosocial services for child behavior problems, particularly via primary care, and ratings of barriers were relatively low despite reporting infrequent service use. Mothers’ responses highlight the need for mental health providers in primary care to ensure accessibility of desired services.
Pediatricians typically serve as "gatekeepers" within the healthcare system for identification, management, and referral of children with behavioral or emotional problems (Jellinek et al., 1999
). Despite recognition by policy makers that mental health services are needed for children within primary care (e.g., Office of the Surgeon General; Horowitz et al., 2002), identification and provision of these services remains inadequate, with at least half of children with behavioral or emotional problems unidentified in this setting (Jellinek et al., 1999).
Mental health services for preschool-age children in primary care are particularly important because early intervention can address problems before they become exacerbated by school and peer risk factors (Neary & Eyberg, 2002; Reid, Webster-Stratton, & Hammond, 2003). Estimates suggest from 10% to 22% of preschoolers seen in primary care present with significant behavior problems (Rich & Eyberg, 2001), and the relatively high frequency of primary care use among preschoolers makes this setting ideal for early mental health screening (McCain, Kelly, & Fishbein, 1999). Long-term outcomes of untreated early behavior problems include child and family distress, poor treatment adherence for physical health problems, and continued mental health problems into adulthood (Riekert, Stancin, Palermo, & Drotar, 1999). Evidence also indicates that aggression among first graders predicts delinquency in adolescence, suggesting that interventions for aggression should occur before first grade (Broidy et al., 2003). The low identification rate of early behavior problems is therefore a concern.
Simonian (2006) identified key factors likely contributing to under-identification of child mental health problems in primary care. Among these were pediatricians’ limited training in mental health, parents’ tendency not to mention concerns without direct pediatrician prompting, inadequate reimbursement for mental health services in primary care, limited use of formal screening tools by pediatricians, brief length of office visits, hesitancy to "label" children with mental health diagnoses, and insufficient availability of referral services for mental health care.
Strategies to address both identification of mental health concerns and delivery of preventive interventions in primary care are essential. Interventions can range from anticipatory guidance to pediatrician, nurse, or mental health specialist care. Survey studies of parents with children 4 years and younger found anticipatory guidance limited for children over 18 months. Parents viewed topics such as feeding, sleeping, and immunizations as being adequately covered; however, parents wanted more anticipatory guidance on discipline (Bethell, Peck, & Schor, 2001; Schuster, Duan, Regalado, & Klein, 2000). Research on pediatrician-delivered psychosocial interventions is scarce, but pediatricians have reported using counseling, education, and behavior management suggestions (Applegate, Kelley, Applegate, Jayasinghe, & Venters, 2003; Garralda, 1998). Nevertheless, a 2004 pediatrician survey found less than half endorsed regularly discussing discipline or behavior management (Olson et al., 2004).
There appears to be consensus that young children's behavior problems are under-identified in primary care and that parents want greater help with behavior management. Yet, little is known about maternal perceptions or preferences for specific mental health services, or whether perceptions and preferences differ for mothers of children with clinically significant behavior problems. This information is essential to determine how best to proceed with assessment and intervention of problem behaviors in primary care.
The purpose of this study was to examine maternal viewpoints on mental health services in primary care. We hypothesized that mothers of young children would prefer prevention/intervention services in primary care more than in other settings, and they would want greater attention on behavior problems during primary care visits than they currently receive. We also explored differences in maternal preferences for child mental health services between mothers whose ratings on the behavior screening measure placed their child in the clinical versus non-clinical range of externalizing behavior problems.
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Method |
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Procedure
This study was approved by the Institutional Review Board at the university health sciences center. Mothers of 3–6-year-olds were recruited for participation from three pediatric primary care facilities in North Central Florida. Flyers posted by the check-in desk at each clinic described two studies: (a) one open to all mothers of 3–6-year-old children, which surveyed parent opinion and preference regarding parenting resources for managing behavior problems of young children; and (b) a second smaller study for parents who completed the survey study and were interested in a parent training study for managing common behavior problems. Research assistants in the pediatric waiting rooms and clinic receptionists answered questions and distributed packets to mothers interested in either study. Study packets included a brief cover letter, an Informed Consent Form, a demographic questionnaire, an Eyberg Child Behavior Inventory (ECBI; measure of child disruptive behavior), and the survey. The cover letter asked parents in both studies to complete the packet and indicated that those interested in the second study could check the indicated box and be contacted later. Parents received a $5 gift card for participation in the survey study when they turned in their completed packet.
Measures
Demographic Questionnaire
This form provided descriptive information on age, sex, and race of the child and mother; maternal caregivers’ relationship to the child; mother's education; and family yearly income.
ECBI Intensity Scale (Eyberg & Pincus, 1999)
The ECBI is a 36-item parent report measure of disruptive behavior. Parents indicate the frequency of common behavior problems on a scale from 1 (never) to 7 (always). Scores can range from 36 to 252, with a mean of 96.6 (SD = 35.2). Test-retest reliability of .80 at 12 weeks and .75 at 10 months has been reported (Funderburk, Eyberg, Rich, & Behar, 2003). The ECBI meets established criteria for primary care screening measures (Eisert, Sterner, & Mabe, 1991; McCain et al., 1999), including simple, quick administration and scoring, good specificity and sensitivity, availability of normative data, strong psychometric properties, and presence of a cutoff score. In addition to distinguishing children with a diagnosed disruptive behavior disorder from nondiagnosed children, the ECBI is effective for measuring sub-threshold problem behavior and changes in behavior problems below clinical levels (Brestan, Eyberg, Boggs, & Algina, 1997). In this study, Cronbach's 
for the ECBI Intensity Scale was .96.
Survey of Parental Attitudes and Practices Regarding Obtaining Mental Health Service1
The survey was created for this study to address focused questions about maternal attitudes and preferences for mental health services in primary care settings for preschool-age children with behavior problems. Survey questions and response choices were developed based on Bright Futures guidelines for pediatricians working with young children (Green & Palfry, 2002; Jellinek, Patel, & Froehle, 2002) and clinical experience. The survey contained 12 questions, with 4–15 response choices, each rated on a 5-point scale, from (1) Never/Definitely Not to (5) Always/Definitely Yes. Questions asked about who parents talk to (or would talk to) about child problem behaviors when/if they occur, current and desired pediatrician practices for child mental health care, preferences for child mental health care (types of services, location), past service use and barriers to service. Each question also had space for an optional write-in response to help ensure that no common response choice was omitted, but there were too few write-in responses for analysis. Specifically, 5 of 12 questions had write-in responses from 1 to 6 mothers per question.
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Results |
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Of 237 study packets distributed to maternal caregivers of 3–6-year-old children in pediatric waiting rooms, 110 completed packets were returned (47% return rate). Forty-four percent of participants were from a private pediatrician's office (Clinic 1), 37% from a university-affiliated primary care center serving primarily low-income families (Clinic 2), and 23% from a university-hospital-affiliated pediatric primary care center serving families with a range of socioeconomic levels (Clinic 3). Each item on the demographic questionnaire was completed by at least 95% of the mothers. Table I shows demographic characteristics of the total sample and participant families by pediatric clinic. Study participants were primarily Caucasian (69%), with modal education of high school completion or some college, and median yearly family income of $30,000–40,000. Mothers’ mean age was 31.6 years (SD = 6.30). Mothers of 70 boys and 40 girls completed the survey, with a mean child age of 56.6 months (SD = 14.3).
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The mean ECBI intensity score for the entire sample was 114.69 (SD = 42.75; T score = 55), ranging from 39 to 226 (T scores = 33 to 87). Thirty-four percent of mothers rated their child's behavior above the clinical cutoff score of 132 (T = 60). Significant differences between clinics were found for ECBI scores, F(2,107) = 3.77, p = .026. Follow-up t tests showed higher scores at Clinic 2 (university-affiliated primary care center serving primarily families with low income) than Clinic 1 (private pediatrician's office), t(83) = 2.72, p = .008. Participants from Clinic 2 were also younger, had fewer years of education, and had lower yearly family incomes than participants from Clinics 1 or 3 (see Table I). Lower yearly family income was the only significant demographic predictor of higher ECBI scores, β = 5.08, p = .032.
We analyzed response trends for the full sample and conducted focused analyses to compare responses of mothers rating their child's behavior in the normal versus clinical range on the ECBI. These focused analyses were conducted for all survey questions, but only significant findings following bonferroni corrections are reported. Family income and maternal race were examined for selected survey questions.
Maternal Discussion of Child Problem Behaviors
Most mothers (66%) reported they often or always talked to the child's other parent about child behavior concerns. For discussion of problem behaviors with pediatricians, 31% of mothers rated this as something they often or always do; however, 38% of mothers indicated they never or rarely talk to the pediatrician about problem behaviors.
At the pediatrician's office, mothers (M = 3.08, SD = 1.33) and pediatricians (M = 3.02, SD = 1.34) were both rated as sometimes likely to ask questions about the child's problem behaviors. As expected, mothers who rated their child's behavior in the clinical range on the ECBI reported higher rates of asking the pediatrician questions than mothers of children with normal range ECBI scores, t(106) = 3.21, p = .002; however, no significant difference was reported in the rate with which pediatricians asked about child behavior as a function of the child's level of problem behavior, t(106) = 1.10, p = .21.
The majority of mothers (87%) indicated mental health specialists never or rarely asked questions about their child's problem behaviors during their primary care visit, suggesting this service is rarely available in these clinics. Mothers of children with elevated ECBI scores reported slightly higher rates than other mothers of being asked by mental health specialists about their child's behavior during pediatrician visits, t(105) = 2.31, p = .023. However, this may be related to limited availability of mental health specialists at the primary care clinics.
The survey also asked mothers what factors might keep them from discussing their child's problem behaviors with the pediatrician if needed. Mothers’ ratings of barriers were generally low overall. Mothers of children with elevated ECBI scores reported higher rates than other mothers of feeling there was not enough time, t(104) = 3.28, p = .001, and feeling uncomfortable asking questions, t(104) = 8.03, p = .003.
When asked about specific behavioral concerns they would discuss if needed, mothers of children with elevated ECBI scores had higher overall rates of talking about problem behavior than other mothers, t(103) = 4.99, p < .001. Table II shows for each group the frequency of discussing specific behavior concerns with pediatricians. For mothers of children with elevated ECBI scores, behaviors discussed most often were (in descending order of frequency): hyperactivity/inattention, tantrums/whining, aggression, and not following directions. Behaviors differed for mothers of children with normal range ECBI scores, whose most frequently discussed problem behaviors were poor eating habits, bedtime/sleep issues, tantrums/whining, and school/daycare learning problems.
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132) for Types of Problem Behaviors Discussed with the PediatricianPediatrician Response to Child Behavior Concerns
Mothers were asked corresponding questions concerning ways their pediatrician currently helps them with child problem behaviors (actual response) and ways they want their pediatrician to help (desired response). Across all item choices, mothers reported desiring more pediatrician assistance with problem behaviors than they reported receiving (see Table III). Mothers indicated interest in most options listed for assistance from the pediatrician, with highest ratings for receiving advice and receiving written information. It was notable that 61% of mothers reported definitely not to probably not wanting medication prescribed for their child's problem behaviors.
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Mothers of children with elevated ECBI scores showed no significant differences from other mothers regarding desired or current pediatrician responses to child behavior problems. Maternal race was related to mothers’ acceptance of medication prescription if needed, with minority mothers reporting higher interest in medication for their children than Caucasian mothers, t(105) = 2.24, p = .027.
Mental Health Service Use
Mothers were asked about past mental health service use as well as their interest in using various mental health services if their child were to show problem behaviors. Across all mothers, 24% reported never having received any type of mental health services for their child, and 62% reported only having read parenting books or handouts to help with child problem behaviors. Reports of past service use were not significantly different between mothers of children with clinically elevated versus non-elevated ECBI scores for any of the services listed (see Table IV).
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In contrast to low actual past service use, mothers’ ratings of interest in using the various mental health services if their child were to show problem behaviors averaged between maybe and probably yes, with the exception of giving their child medication. For medication, the mean response was probably not. In contrast to the similarity in actual past services use, mothers of children with clinical ECBI scores reported significantly higher interest in all of the services than those with non-elevated ECBI scores, except for reading parenting books or handouts (see Table IV).
Ratings by mothers of children with clinical ECBI scores averaged probably yes for all services except medication, which averaged maybe. Ratings by mothers of children in the normal range averaged maybe for all services except medication, which averaged probably not. Rank ordering of interest in various services also differed between groups based on means for each response choice. Mothers of children with elevated ECBI scores rated individual parent programs and calling an expert for advice highest, and mothers of children with non-elevated ECBI scores rated reading parenting handouts and parenting books highest.
Barriers to Obtaining Recommended Services
Mothers were asked to rate barriers to obtaining services if recommended by their pediatrician. It was notable that stigma about mental health services had minimal salience: most mothers reported that not wanting their child labeled as having problems (75%) and feeling discomfort about going to a mental health clinic (74%) were definitely or probably not barriers. The top rated barriers were financial. Cost of services and insurance not paying for services were both rated by 27% as probably to definitely being a barrier. Mothers with the lowest yearly family incomes (<$10,000) had higher ratings for barriers related to transportation and childcare than mothers with higher incomes ($60,000 and higher), F(7,103) = 3.10, p = .005.
Factors Promoting Mental Health Care
In addition to barriers, we examined factors that might increase the likelihood mothers would obtain mental health services for their child. Most mothers indicated they were probably or definitely likely to seek help if their child's behavior were "out of control" (81%). About half the mothers indicated they would likely seek assistance with behavior management as a prevention strategy (49%) or if someone told them they needed help (53%). When asked what factors might facilitate a decision to get help for behavior problems, mothers rated factors related to convenience, sense of comfort, and level of need as all likely to have some influence.
The pediatrician's office was ranked the preferred location for receiving help with child behavior problems for most mothers (M = 3.92, SD = 1.06), with 69% reporting they would probably to definitely participate in services in the pediatrician's office. However, mean scores for all other locations (i.e., child's school, religious center, psychologist's office, psychiatrist's office, mental health clinic, or community center) were in the range of maybe to probably yes.
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Discussion |
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Mothers reported being open to psychosocial services for child problem behaviors, with the pediatrician's office the most preferred service location. Mothers reported wanting more assistance for these issues than they currently receive at pediatrician visits in multiple ways, from simply listening to active behavior change planning. These findings are consistent with our hypotheses about parent preferences for prevention and early intervention services.
Most families of children with clinically elevated ECBI scores had not received previous mental health services of any kind, but they indicated strongest interest in referral for individual parent training or access to expert advice. In contrast, mothers of children without significant behavior problems were interested in access to reading materials. With this sub-clinical population, handouts outlining behavior management strategies may effectively reduce common behavior problems and result in high parent satisfaction with this approach (Harwood, O’Brien, Carter, & Eyberg, manuscript in preparation). Although research is needed to determine if this approach would have lasting benefit, parenting handouts are a cost-effective intervention, if only for short-term improvements in behavior, with potential to prevent more difficult problems for some families.
Medication was rated the least preferred intervention strategy by mothers in this study, regardless of child behavior problem level. This finding suggests behavioral interventions are a more acceptable first-line treatment approach for behavior problems in young children. However, it also suggests that for children for whom pharmacological treatment is determined to be an important intervention component, pediatricians will need to spend time discussing with parents the role of psychotropic medications and potential misconceptions about their use.
In light of maternal preferences for behavioral prevention and early intervention services, the crucial next step is to determine how to proceed in effectively meeting the needs of young children and their families. Suggested strategies include use of non-physician specialists, group well-child visits to allow more time for education, and a call-in number for behavioral and developmental advice (Young, Davis, Schoen, & Parker, 1998). The Healthy Steps for Young Children (HS) program (Minkovitz et al., 2003), designed for children up to age 3, is one primary care model in which specialists provide parent guidance on behavior and development. Parents of 5-year-olds previously in the HS program reported using fewer physical discipline practices than parents in standard pediatric primary care (Minkovitz et al., 2007). Behavior management advice for older preschoolers would likely have similar long-term effects.
However, it is important to consider barriers to programs for families of preschoolers. Although mothers in this sample generally reported few barriers to receiving help for behavior concerns, their highest rated barriers were financial, and those with lowest incomes reported greater barriers related to transportation and childcare. Furthermore, the only characteristic directly related to behavior problem severity in this demographically diverse sample was family income. Thus, families in greatest need of mental health services may be least able to access them.
Addressing financial obstacles to child mental health care is crucial. As one first step, acceptance of the Diagnostic and Statistical Manual for Primary Care (Wolraich, Felice, & Drotar, 1996) could provide a classification system for reimbursement that is better matched to the preventive mental health interventions in primary care. Beyond insurance coverage, an even more complex issue is how to provide access to care for uninsured children. To improve future mental health care in the pediatric setting, cost-effectiveness studies are needed to demonstrate cost offset of early identification and intervention in reducing long-term delinquency and psychopathology and decreasing the 8.9 billion dollars spent annually on mental health care for children and adolescents in the United States (Agency for Healthcare Research and Quality, n.d.).
Limitations to the generalizability of study findings should be considered. Mothers were informed of the possibility of participating in this survey study and an intervention study at the same time. This may have skewed the sample toward children with more problem behaviors. The elevated mean ECBI score for children in this sample suggests this may have been the case. Thus, survey opinions may over-represent those of families more in need of mental health services. Nonetheless, the sample contained a wide range of problem severity, with the elevated mean still within the normal range. Mothers’ responses to questions of actual services, preferences, and barriers remain relevant in this sample, and the range of responses perhaps allowed clearer distinction between clinical versus non-clinical mental health service needs.
The respondents in this study were limited to mothers because, according to consultation with local pediatricians, it is primarily maternal caregivers that accompany children to medical appointments and communicate with pediatricians about mental health needs. However, study of the father's role in decisions about child mental health services may help elucidate potential barriers and facilitators not identified in this study.
Our findings on maternal attitudes and preferences support efforts to develop effective primary care mental health services for children and families. Mothers’ willingness to discuss concerns with their child's physician, even more so when they perceive significant problem behaviors, indicates need for continuing study of service under-utilization. Not only are mothers willing to address mental health concerns in primary care, but they report preferring more advice, written information, and behavior plan formulation than they currently receive. Evidence-based behavior management techniques would be a useful and welcomed preventive intervention for many children and families. At a minimum, mental health information should be available to families through dissemination of written materials in primary care. Ideally, all families would have access to mental health professionals for screening and intervention in their pediatrician's office.
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Acknowledgments |
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This study was supported by funding from the National Institute of Mental Health (T32-HD-007524), the Florida Psychological Association, and The Melissa Institute. We thank Nancy Worthington, MD, and Kathleen Ryan, MD, for their contributions to this research.
Conflicts of interest: None declared.
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Footnotes |
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*Data from this article were previously presented at the National Conference on Child Health Psychology in Gainesville, Florida in April 2006
1Copies of the Survey of Parental Attitudes and Practices Regarding Obtaining Mental Health Service and distributions of responses for each survey question are available by request from the first author.
Received September 30, 2007; revision received October 13, 2008; accepted November 6, 2008
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References |
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Agency for Healthcare Research and Quality (n.d.). Total Expenses for Conditions by Site of Service: United States, 2005. Medical Expenditure Panel Survey Component Data. Generated interactively. Retrieved February 14, 2008, from http://www.meps.ahrq.gov/mepsweb/data_stats/tables_compendia_hh_interactive.jsp?File=HCFY2005&Table=HCFY2005_CNDXP_C&TCOPT1=&TCOPT2=&ModPopCheck=Yes&ModPop=Yes&_Debug=&DDAGELOW=0&DDAGEHIGH=18&Action.x=159&Action.y=6.
Applegate H, Kelley ML, Applegate BW, Jayasinghe IK, Venters CL. Clinical case study: Pediatric residents’ discussions of and interventions for children's behavioral and emotional problems. Journal of Pediatric Psychology (2003) 28:315–321.
Bethell C, Peck C, Schor E. Assessing health system provision of well-child care: The promoting healthy development survey. Pediatrics (2001) 107:1084–1094.
Brestan E, Eyberg SM, Boggs S, Algina J. Parent-child interaction therapy: Parent perceptions of untreated siblings. Child and Family Behavior Therapy (1997) 19:13–28.[CrossRef]
Broidy LM, Nagin DS, Tremblay RE, Bates JE, Brame B, Dodge K, et al. Developmental trajectories of childhood disruptive behaviors and adolescent delinquency: A six-site, cross-national study. Developmental Psychology (2003) 39:222–245.[CrossRef][Web of Science][Medline]
Eisert DC, Sturner RA, Mabe PA. Questionnaires in behavioral pediatrics: Guidelines for selection and use. Journal of Developmental and Behavioral Pediatrics (1991) 12:42–50.[Web of Science][Medline]
Eyberg SM, Pincus D. Eyberg Child Behavior Inventory and Sutter-Eyberg Student Behavior Inventory: Professional manual (1999) Odessa, FL: Psychological Assessment Resources.
Funderburk BW, Eyberg SM, Rich BA, Behar L. Further psychometric evaluation of the Eyberg and Behar rating scales for parents and teachers of preschoolers. Early Education and Development (2003) 14:67–81.[CrossRef]
Garralda E. Needs of special groups: Children. International Review of Psychiatry (1998) 10:134–135.[CrossRef][Web of Science]
Green M, Palfry JS. Bright futures: Guidelines for health supervision of infants, children, and adolescents (2002) 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health.
Horowitz SM, Kelleher K, Boyce T, Jensen P, Murphy M, Perrin E, et al. Barriers to health care research for children and youth with psychosocial problems. Journal of the American Medical Association (2002) 288:1508–1512.
Jellinek MS, Murphy M, Little M, Pagano ME, Comer DM, Kelleher KJ. Use of the pediatric symptom checklist to screen for psychosocial problems in pediatric primary care: A national feasibility study. Archives of Pediatric and Adolescent Medicine (1999) 153:254–260.
Jellinek M, Patel BP, Froehle MC. Bright futures in practice: Mental health – Volume II. Tool kit (2002) Arlington, VA: National Center for Education in Maternal and Child Health.
McCain AP, Kelly ML, Fishbein J. Behavioral screening in well-child care: Validation of the toddler behavior screening inventory. Journal of Pediatric Psychology (1999) 24:415–422.
Minkovitz CS, Hughart N, Strobino D, Scharfstein D, Grason H, Hou W, et al. A practice-based intervention to enhance quality of care in the first 3 years of life: The healthy steps for young children program. Journal of the American Medical Association (2003) 290:3081–3091.
Minkovitz CS, Strobino D, Mistry KB, Scharfstein DO, Grason H, Hou W, et al. Healthy steps for young children: Sustained results at 5.5 years. Pediatrics (2007) 120:658–668.[CrossRef]
Neary EM, Eyberg SM. Management of disruptive behavior in young children. Infants and Young Children (2002) 14:53–67.[Web of Science]
Olson LM, Inkelas M, Halfon N, Schuster MA, O’Connor KG, Mistry R. Overview of the content of health supervision for young children: Reports from parents and pediatricians. Pediatrics (2004) 113:1907–1916.
Reid MJ, Webster-Stratton C, Hammond M. Follow-up of children who received the incredible years intervention for oppositional-defiant disorder: Maintenance and prediction of 2-year outcome. Behavior Therapy (2003) 34:471–491.[CrossRef][Web of Science]
Rich BA, Eyberg SM. Accuracy of assessment: The discriminative and predictive power of the Eyberg Child Behavior Inventory. Ambulatory Child Health (2001) 7:249–257.[CrossRef]
Riekert KA, Stancin R, Palermo TM, Drotar D. A psychological behavioral screening service: Use, feasibility, and impact in a primary care setting. Journal of Pediatric Psychology (1999) 24:405–414.
Schuster MA, Duan N, Regalado M, Klein DJ. What information do parents receive? What information do they want? Archives of Pediatric and Adolescent Medicine (2000) 154:1191–1198.
Simonian SJ. Screening and identification in pediatric primary care. Behavior Modification (2006) 30:114–131.
Wolraich ML, Felice ME, Drotar D, eds. The classification of child and adolescent mental diagnoses in primary care: Diagnostic and statistical manual for primary care (DSM-PC) child and adolescent version (1996) Elk Grove Village, IL: American Academy of Pediatrics.
Young KT, Davis K, Schoen C, Parker S. Listening to parents: A national survey of parents with young children. Archives of Pediatric and Adolescent Medicine (1998) 152:255–262.
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