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Identification and Management of Psychosocial Problems by Preventive Child Health Care
Emily Brugman, MSc;
Sijmen A. Reijneveld, MD, PhD;
Frank C. Verhulst, MD, PhD;
S. Pauline Verloove-Vanhorick, MD, PhD
Arch Pediatr Adolesc Med. 2001;155:462-469.
ABSTRACT
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Objectives To assess the degree to which physicians and nurses working in preventive
child health care (child health professionals [CHPs]) identify and manage
psychosocial problems in children, and to determine its association with parent-reported
behavioral and emotional problems, sociodemographic factors, and general and
mental health history of children.
Design The CHPs examined the child and interviewed parents and child during
their routine health assessments. The parents completed the Child Behavior
Checklist.
Setting Nineteen child health care services across the Netherlands, serving
nearly all school-aged children routinely.
Subjects Of 4970 children aged 5 through 15 years, eligible for a routine health
assessment, 4480 (90.1%) participated.
Main Outcome Measures Identification and management of psychosocial problems by CHPs.
Results In 25% of all children, CHPs identified 1 or more psychosocial problems.
One in 5 identified children were referred for further diagnosis and treatment.
Identification of psychosocial problems and subsequent referral were 6 times
more likely in children with serious parent-reported problem behavior according
to the Child Behavior Checklist total problem score (8% of total sample).
However, CHPs identified no psychosocial problems in 43% of these children
and therefore undertook no action. Other child factors associated with CHPs'
identification and referral were past treatment for psychosocial problems,
life events, and academic problems. After adjustment for these, sociodemographic
characteristics did not predict referral.
Conclusions The CHPs identify psychosocial problems in school-aged children frequently
and undertake actions for most of them. Screening for psychosocial problems
may be a promising option to reduce these problems, but accurate identification
should be enhanced.
INTRODUCTION
PSYCHOSOCIAL problems, such as behavioral, emotional, and educational
problems, are highly prevalent among children and can severely interfere with
everyday functioning. Only a minority of the children with such problems receive
mental health care.1, 2, 3, 4
In a study conducted among more than 2000 Dutch children,3
only 13% of the children with behavioral and emotional problems had been referred
to mental health services in the year before the assessment.
In the Netherlands, preventive child health care is one of the most
important low-threshold services for the early detection of psychosocial problems
in children. This preventive health care is provided unasked to all children
living in the Netherlands by community physicians and nurses working in preventive
child health care services (child health professionals [CHPs]).5, 6, 7
These services offer publicly funded preventive programs (screening, vaccinations,
and health education and promotion) for all children from birth to 19 years.
As part of this system, more than 90% of all children undergo 3 to 4 assessments
by a CHP during their school careers. Nearly all services offer assessments
to children in grade 2 of primary school (mean age, 5-6 years) and grade 2
of secondary school (mean age, 13-14 years), and most in grade 4 or 5 and
grade 7 or 8 of primary school.8 (In the Netherlands,
primary school takes 8 years, and secondary school, 4 to 6 years, depending
on its level.) These assessments consist of a general physical examination
including some standardized screening procedures, and an interview with parents
or with older children themselves concerning their physical and psychosocial
problems. The assessments take approximately 10 minutes. At the end of the
assessment, the CHP decides whether there is any need for counseling, follow-up,
or referral. If CHPs identify more serious problems, they always decide to
refer the child and the parents to other professional services, as they do
not offer curative care themselves.
Originally, the main role of preventive child health care was restricted
to the prevention of physical conditions. Recently, its focus has been shifting
to mental health. Little is known yet about the effectiveness of child health
care in detecting psychosocial problems in children, and about its role in
the referral pathway to specialized mental health services.
The aim of the present study was first to assess the degree to which
CHPs identify and manage psychosocial problems among children aged 5 through
15 years in the general population. Second, it assesses which child factors
are associated with the identification of psychosocial problems by CHPs, and
with their referral for further evaluation and treatment.
SUBJECTS AND METHODS
SAMPLE
We obtained our sample by means of a 2-stage selection procedure. In
the first stage, a random sample of 19 of the 63 child health care services
was drawn, after stratification by region and degree of urbanization of their
district. In the second stage, each child health care service provided a sample
of 75 children for each of 4 grades (second, fourth, and seventh grades of
primary school, and the second grade of secondary school) by inviting all
children in 3 school classes per grade to participate. The selected classes
of secondary school should represent different levels of education, as the
Dutch secondary school system consists of different types of schools. Children
in schools for children with special needs were not included in the study,
as the system of preventive health assessments is different in these schools.
Of the 4970 eligible children, 4480 (90.1%) participated. Differences
between responding and nonresponding children by sex, age, ethnicity, and
degree of urbanization were small, according to Cohen effect size index w (range of w, 0.01-0.08).9
PROCEDURE AND MEASURES
The data were collected in a standardized way as part of the routine
preventive health assessments from October 1, 1997, to June 30, 1998. The
design of the study was approved by the local medical ethical committee. It
was similar to that of previously reported studies on child health10, 11 and growth and maturation.12, 13 The Child Behavior Checklist (CBCL)14 was mailed to parents, along with the standard invitation
to the preventive health assessment. The CBCL was completed by the parents
and returned to the researchers in a sealed envelope. After each child's physical
examination, the CHP obtained sociodemographic and mental health history information
by following a standardized interview with the parents or, if the child was
12 years or older, with the child himself or herself. Ninety-six percent of
children in primary education and 11% of children in secondary education were
accompanied by their parent(s). After each assessment, the CHP filled out
the following question: "Does the child have a psychosocial problem, at this
moment?" (yes or no) and scored the type of the identified problem(s) on a
precoded list. Children with only risk indicators for the development of psychosocial
problems, such as parents with psychiatric problems or other family problems,
had to be coded as no. If a problem was identified, the CHP was asked to rate
the severity of the problem (mild, moderate, or severe) and to indicate how
the problem was managed (precoded question).
Sociodemographic variables assessed were sex, age, ethnicity, family
composition, siblings living in the family at the time of study, educational
level and employment status of the parent(s), and degree of urbanization.
Ethnicity was based on the native country of the child and of both biological
parents. At least 2 of them had to be born outside the Netherlands to qualify
as non-Dutch. Parental educational level was used as a measure of socioeconomic
status and was based on the highest degree completed by the father or mother.
Degree of urbanization was assessed by means of the postal code of the address
of residence.15
Data on general and mental health history concerned whether the child
was (point prevalence) or had been (lifetime prevalence) treated for psychosocial
problems. Response options included mental health professionals (eg, psychiatrist
or psychologist), medical professionals (eg, general practitioner or pediatrician),
and other professionals (eg, specialized family help or parenting support).
In addition, life event(s) in the previous year (such as hospitalization,
death of family member, unemployment, or divorce) were assessed in a standardized
way. Finally, 2 competence items of the CBCL were included (see next paragraph).
The CBCL was used to assess the parent's report of the child's behavioral
and emotional problems during the preceding 6 months.14
The good reliability and validity of the CBCL, established by Achenbach,14 were confirmed for the Dutch translation.16 The CBCL consists of 20 competence items and 120
problem items. In this article only 2 competence items were used (if the child
had ever had any problems at school [academic or other] and if the child had
a physical illness or general or mental handicap). Eight syndrome scales,
2 broadband groups of syndromes designated internalizing and externalizing, and a total problem score
were computed. Internalizing consisted of the withdrawn, somatic complaints,
and anxious/depressed syndrome scales, and externalizing consisted of the
delinquent and aggressive behavior syndrome scales. Cases were subsequently
allocated to a normal range or a clinical range of the scoring distributions
based on the Dutch normative sample.15 Cutoffs
were set at the 97th percentile for the 8 syndrome scales and at the 90th
percentile for the total problem and internalizing and externalizing scales.
ANALYSIS
First, we examined the prevalence of psychosocial problems as identified
by CHPs. Second, we analyzed the management strategies used by CHPs, also
in relation to the severity of the problems. We used  2 tests
to determine the statistical significance of differences between distributions
of categorical data. Third, we assessed which child factors (CBCL problem
scales, sociodemographic variables, and general and mental health history
variables) were related to the identification of psychosocial problems by
CHPs (no or yes), by means of univariate and multivariate logistic regression
analyses. We repeated these analyses regarding a referral for psychosocial
problems by CHPs (no or yes). All independent child variables were dichotomized.
The regression analyses were all performed with multilevel techniques
because of the hierarchical nature of the data: characteristics of a CHP may
have an impact on the assessments of all children who are seen by him or her.
Multilevel models account for this clustering of individual data by CHP.17, 18 In all multilevel logistic regression
models used, the random components of variances were assessed both at the
individual and at the CHP level (n = 78 CHPs). Random variances at the child
level were assumed to be approximately binomially distributed.17
Models were fitted by means of the most accurate procedure available, ie,
by using a predictive quasi-likelihood procedure in combination with a second-order
Taylor expansion series.17
Prevalence estimates presented in the tables and text are weighted by
region and age, to adjust for differences between the study population and
the Dutch population. Test statistics, odds ratios, and 95% confidence intervals
were calculated on the basis of the unweighted data.
RESULTS
PROBLEM IDENTIFICATION
In 25% of all children, the CHP identified 1 or more psychosocial problems.
In 52% of these cases the severity of the problems was rated as mild, in 37%
as moderate, and in 11% as severe. At the time of the study, 2% of all children
were being treated for psychosocial problems by a mental health professional,
2% by another medical professional, and 1% by other professionals. The first
group was excluded from further analyses, as psychosocial problems were expected
to be already known among these children.
MANAGEMENT STRATEGIES
The CHPs undertook actions in 85% of the nontreated children with identified
psychosocial problems. Various management strategies were used: advice or
reassurance (62%); consultation with school, colleagues, or official authorities
(45%); referral to another professional (21%); and follow-up (19%).
Management strategies varied according to the severity of the problems
as rated by the CHP (Table 1).
Follow-up, consultation, and referral were more frequent in children whose
psychosocial problems were rated moderate or severe. All children with severe
psychosocial problems for whom no actions were undertaken (6%) were already
being treated by a medical or nonmedical professional at the time of the assessment.
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Table 1. Management Strategies of CHPs by Severity of Problems as Rated
by CHPs*
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CHILD FACTORS RELATED TO PROBLEM IDENTIFICATION AND REFERRAL
Of the nontreated children, 8% had a CBCL total problem score in the
clinical range. Table 2 presents
the number of nontreated children with a CBCL total problem score in the normal
and clinical range who were identified by CHPs as having psychosocial problems,
and the management strategies used.
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Table 2. Identification of Psychosocial Problems by CHPs and Management
Strategies Used in Relation to the CBCL Total Problem Score*
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The CHPs identified psychosocial problems in 57% of the children with
a CBCL total problem score in the clinical range (cutoff at 90th percentile).
This percentage was 67% for those scoring above the 98th percentile of the
CBCL total problem score and 80% for the children scoring above the 99th percentile.
The CHPs identified psychosocial problems in 21% of the children with a CBCL
total problem score in the normal range. These problems were rated as mild
in 61% of the cases, moderate in 33%, and severe in 6%; the rating of problems
of children scoring in the clinical range of the CBCL total problem score
was mild in 36%, moderate in 48%, and severe in 16% (2 = 43.04; P<.001).
No actions were taken in 47% of all children with a CBCL total problem
score in the clinical range; in 93% of these cases, this was because CHPs
had identified no psychosocial problems. Referral to another professional
was 4 times more likely in children with a CBCL total problem score in the
clinical range (17%) than in those scoring in the normal range (4%).
Table 3 presents the association
of CBCL problem scales with the identification of, and referral for, psychosocial
problems by CHPs. Odds ratios for all CBCL scales were high, indicating that
children who have scores in the clinical range of different CBCL problem scales
were between 2.69 and 9.64 times more likely to be identified with or referred
for psychosocial problems by CHPs.
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Table 3. Results Derived From Multilevel Univariate Logistic Regression
Analyses of CBCL Problem Scales Increasing the Probability of Identification
of, and Referral for, Psychosocial Problems by CHPs*
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Concerning the sociodemographic variables, Table 4 shows that CHPs identified psychosocial problems relatively
frequently in a number of groups: boys, younger children, children with parents
of low educational level, children of single parents, children of unemployed
parents, and children living in highly urbanized areas. In contrast, they
referred only children from single parents more frequently.
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Table 4. Results Derived From Multilevel Univariate Logistic Regression
Analyses of Sociodemographic Variables Increasing the Probability of Identification
of, and Referral for, Psychosocial Problems by CHPs*
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With the exception of the parental report of physical illness or handicap
of the child, all general and mental health history variables (Table 5) were significantly related to both the identification of
psychosocial problems by CHPs and a referral for psychosocial problems. The
identification of and referral for psychosocial problems was most frequent
in children who had been treated for psychosocial problems in the past by
a medical professional, such as a general practitioner or pediatrician.
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Table 5. Results Derived From Multilevel Univariate Logistic Regression
Analyses of General and Mental Health History Variables Increasing the Probability
of Identification of, and Referral for, Psychosocial Problems by CHPs*
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Table 6 provides the results
of multiple logistic regression analyses. It lists variables that were significantly
related to the identification of psychosocial problems by CHPs (in the second
column) and to referral for these problems (in the third column) after adjustment
for the effect of all other variables. Because of the hierarchical structure
of the CBCL, 3 models were tested for both dependent variables: one set containing
the 8 CBCL syndrome scales, one set containing the internalizing and externalizing
scales, and one set containing only the total problems scale. As the results
were almost identical, only the odds ratios of the sociodemographic variables
and general and mental health history variables of the first model, thus with
adjustment for the 8 CBCL syndrome scales, are listed in Table 6. These results show that a referral for psychosocial problems
was independent of sociodemographic variables, but still more likely in children
with scores in the clinical range of the CBCL problem scales somatic complaints,
social problems, and aggressive behavior, and with past treatment for psychosocial
problems, life events, and academic problems.
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Table 6. Results Derived From Multilevel Multiple Logistic Regression
Analyses of Significant Child Factors Increasing the Probability of Identification
of, and Referral for, Psychosocial Problems by CHPs*
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COMMENT
Physicians and nurses working in preventive child health care identified
psychosocial problems in one quarter of the general population of children
aged 5 to 15 years. The severity of these cases was mainly rated as mild or
moderate. The CHPs undertook actions for most of the identified cases of psychosocial
problems, mainly in the form of advice to parents, or consultation with schools
or their own colleagues. Identification of psychosocial problems and subsequent
referral were 6 times more likely in children with serious parent-reported
problem behavior according to the CBCL total problem score. However, CHPs
identified no psychosocial problem in 43% of the children with a CBCL total
problem score in the clinical range. Furthermore, they identified a psychosocial
problem in 21% of the children with normal CBCL results. Such an imperfect
agreement is likely because of several reasons.
First, CHPs identify a broad range of psychosocial problems in children
and adolescents—including mild problems—many of which do not need
direct treatment, whereas high CBCL scores typically occur among children
who are referred for mental health services. The CHPs can thus be expected
to identify more problems, which are on average less severe. Our results show
that they do so indeed. Moreover, when the CBCL cutoff was increased from
the 90th to the 99th percentile, the percentage of the children with a CBCL
total problem score in the clinical range who were identified with psychosocial
problems by CHPs increased from 57% to 80%.
Second, even if they intend to identify the same children, both the
CBCL questionnaire and the CHP may make errors in the identification of the
relevant children. Regarding the CBCL, for instance, the sensitivity and specificity
of the Dutch version at the cutoff for the clinical range are 0.66 and 0.82,
respectively, with referral to mental health care as morbidity criterion.15 Considering identification by the CHP as the gold
standard, this would mean that about one half of all elevated CBCL total problem
scores were false-positives, for which the CHP was right in not identifying
these children. Almost certainly, the reverse is also true.19, 20, 21
Third, the CBCL score is based on only 1 informant, the parent, whereas
the CHPs' identification is based on the parent, the child, and sometimes
the teacher as informants. Disagreement between different informants on behavioral
or emotional problems of children has been extensively documented. Achenbach
et al22 demonstrated a mean Pearson correlation
of 0.28 between different informants (parents, teachers, mental health workers,
observers, and peers) and of 0.22 between children and other informants. Additional
analyses indeed showed that identification of psychosocial problems by CHPs
was more likely among children with a CBCL total problem score in the clinical
range who were accompanied by their parents (69% vs 48% for unaccompanied
children with such a score in secondary school; in primary school, nearly
all children were accompanied by at least 1 parent).
Our study shows further that the effect of some sociodemographic variables
(sex, family composition, and socioeconomic status) on the CHPs' identification
of psychosocial problems could be completely explained by behavioral and emotional
problems measured by the CBCL and by general and mental health history variables.
Apparently, such problems and such a history are quite common among boys,
children of single parents, children of parents with a low education level,
and children of unemployed parents. In contrast, regardless of behavioral
and emotional problems according to the CBCL and general and mental health
history, CHPs identified more psychosocial problems in young children and
those living in highly urbanized areas. Furthermore, mental health history,
the sociodemographic characteristics listed above, and scores on 4 CBCL syndrome
scales also explained the more frequent identification of children with an
elevated score on the other syndrome scales. These 4 are the CBCL scales somatic
complaints, thought problems, attention problems, and delinquent behavior.
Interestingly, after adjustment for the other variables, CHPs in general identified
children with an elevated score on the internalizing scale somewhat more frequently
than those with an elevated score on the externalizing scale, whereas one
might expect that the latter are easier to identify. It is difficult to compare
our results with those of other studies because none of these used CBCL syndrome
scales to characterize problems; the results of other approaches, such as
diagnoses based on the Diagnostic and Statistical Manual
of Mental Disorders, Third Edition23
or the Diagnostic and Statistical Manual of Mental Disorders,
Revised Third Edition,24 do not always
correspond with CBCL syndrome scales.25, 26
It might be hypothesized that a contribution of general and mental health
history to identification might at least partially be due to familiarity of
the CHP with the child and the parents.27, 28
In our study, this is difficult to assess because we only included first encounters
during the regular preventive health assessment, and Dutch CHPs do not provide
curative care. However, if a CHP identified psychosocial problems, the likeliness
of a CBCL total problem score in the clinical range was higher (23%) if this
identification was also based on previous information of a CHP on the child
than if it was based on other information sources (17%; 2
= 11.83; P = .003).
Regarding referral for psychosocial problems to other professional services,
none of the sociodemographic variables was predictive. The CHPs thus seemed
to base their decision for referral almost completely on information regarding
the mental health of a child, and not on the child's sociodemographic background.
Regarding specific CBCL scales, referral occurred more frequently among children
with an elevated score on the internalizing scale and on 3 syndrome scales.
The first result corresponded with that on identification. However, the more
frequent identification of psychosocial problems among children with elevated
scores on the withdrawn and anxious/depressed scales did not correspond with
more frequent referral of them, whereas children with an elevated score on
the somatic complaints scale were referred more frequently without an increased
frequency of identification.
Our results also show that CHPs did not undertake action, or only gave
advice or reassurance, for a substantial portion (57%) of the children with
a CBCL total problem score in the clinical range. The main reason for this
lack of follow-up was that CHPs did not identify these children, as discussed
in previous paragraphs. Several other studies have shown similar results.27, 28, 29 Improvements regarding
this may be reached in several ways,19, 20, 21
for instance, by improving expertise and diagnostic tools, and by making more
time available for diagnosis.
The response in this study was very high (90%), and our sample is considered
representative of children in primary and secondary school eligible for a
routine health assessment by child health care, with respect to sex, age,
and socioeconomic background.30 Only non-Dutch
children and children living in highly urbanized areas were underrepresented.15, 31, 32 As our study showed
that CHPs identified psychosocial problems among these groups rather frequently,
the actual prevalence will probably be slightly higher. Excluded from this
study were children in special education, another group that probably has
much higher rates of psychosocial problems. However, this group consisted
of only 4% of all children.33 The prevalence
of identified psychosocial problems would thus be only slightly higher (28%)
if CHPs identified them in all these children.
Recent US studies have shown prevalence rates of psychosocial problems
as identified by clinicians (pediatricians, primary care physicians, or pediatric
nurse practitioners) in school-aged children ranging from 10% to 27%.27, 28, 29, 34, 35
Horwitz and coworkers28 reported that clinicians
identified psychosocial or developmental problems among 27% of 1886 children
aged 4 to 8 years who visited community-based, primary care pediatric practices;
of the identified children, they referred 16% to specialty services outside
their own practice. In another study, family physicians identified psychosocial
or developmental problems in approximately 22% of 898 children aged 5 to 15
years, and referred 46% of the identified children to mental health services.29 Kelleher and coworkers35
reported that pediatric and family practice clinicians identified psychosocial
problems among 19% of a national sample of 21 065 pediatric visitors
aged 4 to 15 years and, in a subsample, referred 40% of those identified,
and identified 57% of those with an elevated score on the Pediatric Symptom
Checklist.27 Finally, Jellinek and coworkers34 reported much lower rates of psychosocial dysfunction
in the same sample on the basis of the Pediatric Symptom Checklist (5573 children
aged 4-5 years, 10%; 15 492 children aged 6-15 years, 13%). They further
summarized 7 previous smaller studies with similar design (n = 115 to 379)
in which Pediatric Symptom Checklist identification rates varied from 7% to
22%. It is not easy to compare these rates with our results, however. First,
these studies were performed in primary health care settings and consisted
of well child and other visits, whereas our study was performed at a community
level. Furthermore, sample characteristics and the exact definition of psychosocial
problems differed, as well as the clinical criteria for defining problem behavior.
For example, in some studies, clinicians were asked directly for the presence
of "psychosocial or developmental problems,"29, 35
whereas others asked clinicians to fill out more elaborate checklists.28
The stability of problem behavior from childhood into adolescence, as
well as into adulthood, has been demonstrated in several studies.36, 37, 38, 39, 40, 41, 42
For example, 39% of a general population sample of children who scored in
the clinical range of the CBCL total problem scale still scored in that range
at follow-up 8 years later.40 Thus, children
do not easily grow out of these problems. At the same time, results of randomized
controlled trials show that treatment programs can be effective in the reduction
of problem behavior.43, 44, 45, 46
Durlak and Wells47 evaluated the outcomes of
130 secondary preventive mental health programs for children and adolescents
and concluded that such programs significantly reduce problems and increase
competencies. Hence, the early detection of psychosocial problems, for instance
by CHPs, may improve their prognoses in later life, if such preventive mental
health programs are properly implemented in daily practice.21
Additional efforts may be needed to reach this in preventive child and adolescent
services.8, 21, 48, 49
The present study was the first Dutch national study performed on the
identification and management of psychosocial problems by preventive child
health care. Its results show that CHPs identify a substantial number of children
with minor and major psychosocial problems during their routine preventive
health assessments and undertake some form of action for most of the identified
children. However, improvement of the skills and tools of CHPs regarding the
identification of psychosocial problems may be necessary, as they do not identify
psychosocial problems in a considerable proportion of the children with serious
behavioral or emotional problems according to the CBCL. If identified on a
timely basis, at least some of these children might also benefit from treatment.
Our results thus show that screening for psychosocial problems by physicians
and nurses working in preventive child health care may be a promising option
to reduce these problems, but that their accurate identification should be
further enhanced.
AUTHOR INFORMATION
Accepted for publication September 8, 2000.
This study was carried out by TNO Prevention and Health, Leiden, the
Netherlands, in cooperation with the Dutch Association of Municipal Public
Health Services, Utrecht, and was financially supported by the Ministry of
Health, Welfare and Sports and the Praeventiefonds (grant 28-2628-2), The
Hague.
We thank Ton Vogels, MSc, and Peter van der Heijden, PhD, for their
helpful suggestions.
From TNO Prevention and Health, Leiden, the Netherlands (Ms Brugman
and Drs Reijneveld and Verloove-Vanhorick); and the Department of Child and
Adolescent Psychiatry, Erasmus University Rotterdam, Academic Hospital Rotterdam-Sophia,
Rotterdam, the Netherlands (Dr Verhulst).
Corresponding author and reprints: S. A. Reijneveld, MD, PhD, TNO
Prevention and Health, PO Box 2215, 2301 CE Leiden, the Netherlands (e-mail: SA.Reijneveld{at}pg.tno.nl).
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