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Physicians' Attention to Parents' Concerns About the Psychosocial Functioning of Their Children
Beth G. Wildman, PhD;
Ali H. Kizilbash, MA;
William D. Smucker, MD
Arch Fam Med. 1999;8:440-444.
ABSTRACT
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Background Epidemiological data indicate that approximately 20% of children have psychosocial problems, yet less than 2% of children are seen by mental health specialists each year. Primary care physicians tend to identify children with psychosocial problems when parents discuss concerns with them.
Objective To examine factors related to physicians' attention to parental disclosures.
Design Parents reported the psychosocial functioning of themselves and their children. Physicians reported the psychosocial functioning of 75 children and whether the parent disclosed psychosocial concerns to them.
Setting Ambulatory care clinic of a community-based, university-affiliated, residency training program.
Participants Seventy-five parents of children aged 2 to 16 years who presented for routine primary care, and 26 physicians.
Main Outcome Measures Beck Depression Inventory (parental distress), Eyberg Child Behavior Inventory (child behavior problems), physician and parent report.
Results Physicians identified 50.0% of children with clinically significant behavior problems. Logistic regression indicated that parental disclosure was the only significant predictor of physician identification (P<.002). When children had clinically significant behavior problems, physicians were more likely to report disclosures by parents (45.0% vs 5.7% for parents of children with and without behavior problems, respectively). Physicians were more likely to report parental disclosure when parents reported personal psychosocial distress (38.9% for distressed vs 5.7% nondistressed parents).
Conclusions Parental disclosure of concerns was a better predictor of physician identification of child psychosocial problems than was the presence of child behavior problems. Physicians responded more frequently to the disclosures of potential problems by parents of children with clinically significant psychosocial problems. They also attended more frequently to disclosures about behavior problems when the parent was also experiencing psychosocial distress.
INTRODUCTION
EPIDEMIOLOGICAL RESEARCH has suggested that approximately 15% to 20% of children experience psychosocial problems, yet less than 2% of children receive services from mental health specialists.1-5 Most children with psychosocial problems are treated by primary care physicians who fail to identify those children.6-8 Improvement of identification of psychosocial problems by primary care physicians is important because: (1) managed care companies often require referral by primary care physicians for patients to receive specialty mental health services, and (2) Healthy People 2000 has set a goal to improve the rate at which primary care physicians identify and manage children with psychosocial problems as an integral component for reducing mental health problems in children and adolescents.9 Little is known about the differences between those children whom primary care physicians identify with psychosocial problems, and those with psychosocial problems whom primary care physicians fail to identify. Understanding these differences may help primary care physicians attend to factors that will improve their rate of identification.
Several factors have been discussed as contributing to physicians' failure to identify children with psychosocial problems who present to them. Among these factors are lack of adequate physician training, disinclination to attach potentially deleterious labels to children, and failure of parents to disclose relevant concerns.10-15 Previous research has suggested that physicians identify and treat children when parents discuss psychosocial concerns with them.15-16 However, little is known about when physicians attend to the disclosures of parents.
The present research evaluated factors related to parental disclosure of psychosocial concerns about their child and factors related to physician recognition of these disclosures. Previous research has suggested that parental report of psychosocial concerns in children may be related to parental psychosocial distress.17-20 The present research evaluated the relationship between child behavior problems and parental distress, and disclosure of concerns about the child's psychosocial functioning to the physician, as well as physician report of these disclosures.
PARTICIPANTS AND METHODS
PARTICIPANTS
Participants were 75 parents of children between the ages of 2 and 16 years whose children had an appointment with a physician at the Family Practice Center of Akron City Hospital, Akron, Ohio. The Family Practice Center is an ambulatory care clinic of a community-based, university-affiliated, residency training program located in a midsized, midwestern city. There are 26 physicians, ranging in experience from interns to faculty, at the Family Practice Center. Participants who did not speak English fluently, had completed similar instruments at the Family Practice Center previously, or who failed to complete all the instruments were excluded from the current study. All eligible parents and physicians signed informed consent before participating.
INSTRUMENTS
In addition to their psychometric properties, selection of instruments was based on their applicability and prior use with community or primary care samples, as well as with psychiatric samples.
Beck Depression Inventory
This instrument was used to assess parental distress. Research has supported the use of the Beck Depression Inventory (BDI)21 as a measure of psychological distress, rather than exclusively as a measure of depression.22-26 As suggested by Kendall et al,26 a score of 10 or higher was used to indicate distress.
Eyberg Child Behavior Inventory
The Eyberg Child Behavior Inventory (ECBI)27 was used to assess child behavior problems. The ECBI was selected as the instrument to assess child psychosocial problems for 4 major reasons: (1) The ECBI is brief and could readily be completed before the physician saw the child; (2) It is well standardized and has a high correlation with the Child Behavior Checklist, which is much longer and has been widely used in epidemiological research28; (3) The ECBI assesses both the presence of a behavior problem (Problem Scale) and frequency of behavior problems (Intensity Scale); and (4) The ECBI assesses acting out behavior problems, such as aggression and oppositional behavior, which are the most frequent diagnoses in pediatric offices.7, 29 Following standard procedure, the Problem and Intensity Scales of the ECBI were scored separately, and the cutoff scores of higher than 11 on the Problem Scale and higher than 127 on the Intensity Scale were used to signify the presence of clinically relevant behavior problems.30
Family Demographic Questionnaire
This instrument contained demographic questions about the family, such as child's race, parental income and education, and type of medical insurance.
Parent Exit Questionnaire
This instrument contained questions regarding parent perception of physician discussion of mental health issues during the visit. The question from the Parent Exit Questionnaire that was analyzed for the present research was: "Did you and your doctor talk about behavioral or emotional issues regarding your child today?"
Physician Checklist
This instrument was based on categories developed by the World Health Organization, Geneva, Switzerland, and was adapted from previous research done in primary care settings.11, 16 Physicians were asked to complete this brief measure on every patient visiting the Family Practice Center. The Physician Checklist was used to assess physician recognition of parent-raised concerns about their child's psychosocial functioning, and physician identification of child behavior problems. Questions from the Physician Checklist that were used in the present research were: "Did the child's parent raise any psychosocial concerns he/she had about this child?" and "Are you concerned the child might have any type of psychosocial or developmental problem?"
PROCEDURE
Undergraduate research assistants used a standard protocol to recruit parents visiting the Family Practice Center with their children. All participants in the present study completed the measures during the time of their visit. In addition, physicians were asked to complete the Physician Checklist within 24 hours of the visit.
RESULTS
Of the 291 parents initially asked to participate in the study, 212 were eligible for participation and agreed to do so; 79 were ineligible because they had completed similar questionnaires for this or other related research at the Family Practice Center. Questionnaires were completed by 160 of these 212 potential participants. The remaining 52 participants returned incomplete questionnaires. Of the 160 completed questionnaires, 75 of them had matching Physician Checklists. These 75 cases resembled the entire 160 participant sample with respect to the person completing the forms, child age, parent education, insurance status, racial composition, and number of children per family. Most of the data (90.7%) were collected from mothers. Of the remaining questionnaires, 6.7% were completed by fathers and 2.6% were completed by other relatives or foster parents. The children's ages ranged from 2 to 16 years, with a mean age of 7.2 years. Type of medical insurance and parental education were used as indicators of socioeconomic status. Of the 75 participants, 52.0% had private insurance, 41.3% had Medicaid, 5.3% were uninsured, and the remaining 1.4% did not respond to this question. Most of the participants had some education beyond high school: 9.3% had not completed high school, 33.3% of the participants had a high school diploma, another 34.7% had some college experience, 9.3% completed a Bachelor's degree, 9.3% had a graduate degree, and the remaining 4.1% did not respond to this question. The adult participants were white (73.3%), African American (22.7%), Hispanic (1.3%), and other (2.7%). Table 1 summarizes the demographic composition of the sample.
Among the participants, 20.0% of the parents (n=15) scored in the distressed range on the BDI, 13.3% (n=10) of the children had ECBI scores in the clinical range, 30.7% (n=23) parents reported that they disclosed psychosocial concerns about their child to their child's physician, and physicians reported that parents disclosed psychosocial concerns 13.3% of the time (n=10). Physicians reported that 50.0% of the children with elevated ECBI scores were experiencing psychosocial problems, leaving 50.0% of the children with elevated ECBI scores (n=5) unreported by the physicians.
To evaluate the relationship between parent and child psychosocial functioning, parental disclosure of concerns to their child's physician, and physician recognition of parental disclosure of psychosocial concerns, a series of logistic regressions were performed using SPSS/PC (SPSS, Chicago, Ill). Factors related to parent report that they disclosed concerns to their child's physician were evaluated by a logistic regression conducted using the BDI and ECBI Problem and Intensity Scale scores to predict whether parents reported that they disclosed psychosocial concerns to their child's physician. The ECBI Intensity score, which assesses frequency of behavior problems, was the only significant predictor of whether parents reported disclosing psychosocial concerns to physicians ( =-.013; SE=.005; P<.02). Neither scores on the BDI nor the ECBI Problem Scale significantly contributed to the prediction of parent report of disclosure.
Parents and physicians agreed on whether there had been parental disclosure 80.0% of the time. However, most of this agreement was based on agreement that disclosure did not occur. Overall, there were significant differences between parent and physician reports of disclosure, ( 21 [N=75]=19.10, P<.001). Physicians failed to report parental disclosure 60.9% of the time when parents reported disclosing psychosocial information. Physicians were more likely to report parental disclosure of concern about their child's psychosocial functioning when parents were psychosocially distressed (ie, had elevated BDI scores) (21 [N=75]=11.53; P<.001). When parents scored as distressed on the BDI, physicians reported that parents discussed child psychosocial issues 38.9% of the time. When no parental distress was reported, physicians reported that only 7.3% of the participants discussed their child's psychosocial functioning. Physicians tended to report the disclosures of parents of children with clinically significant behavior problems, as indicated by a significant relationship between clinically elevated scores on the ECBI and physician report of parent concern about their child's psychosocial functioning (21 [N=75]=14.66; P<.001). When parents rated their children in the clinically relevant range of the ECBI, 45.0% of the time physicians reported that parents raised psychosocial concerns about their child. In comparison, for only 5.7% of the children with ECBI scores below the range of clinical relevance did physicians report that parents raised psychosocial concerns. A logistic regression indicated that the ECBI Problem Scale, which assesses whether the behavior is a problem to the parent, was the only variable that was significantly related to physician report of parental disclosure (=-.17, SE=.05; P<.001). Further, another logistic regression indicated that report of parental disclosure was the only variable that significantly predicted physician identification of child psychosocial problems (=-1.17, SE=.37; P<.002). Parental distress and ECBI scores did not predict physician identification.
For physicians in practice, a key question is whether they are accurately attending to children who are presenting with psychosocial problems. When parents reported disclosure of concern but physicians reported that no disclosure had occurred, 28.6% of the ECBI scores were in the clinically relevant range. However, 66.7% of the ECBI scores were in the clinically relevant range when parents and physicians agreed that parental disclosure occurred.
COMMENT
The results of the present study support the need to continue emphasizing factors important for physician identification of child psychosocial problems. The physicians in the present study failed to identify 50.0% of children with psychosocial problems. Similar to previous research, the best predictor of physician identification was parental disclosure of concerns about their child's psychosocial functioning.14-16 The present data further suggest that physicians are more likely to attend to the disclosures of parents whose children have clinically significant behavior problems.
Although parental disclosure of concerns about the psychosocial functioning of their child was associated with physician report of child psychosocial problems, physicians failed to record psychosocial problems in a substantial number of children whose parents reported discussing their concerns about their child's psychosocial functioning with their child's physician. Factors related to parental disclosure of child behavior problems were different from the factors related to physician report of parental disclosure. Understanding the differences between the factors related to parental disclosure and physician report of disclosure are particularly important because parental disclosure seems to be closely related to physician identification, both in this study and in previous research.14-16 The findings of this study indicate that physicians may fail to attend to parental disclosures about child behavior problems when parents are not personally experiencing psychosocial distress. That is, children with behavioral problems who had parents who did not self-report personal distress (ie, anxiety or depression) were less likely to be identified by their physicians than children whose parents were themselves experiencing psychosocial distress. Parental distress was not associated with parental report of disclosure of concerns to their child's physician. Parents tended to disclose their concerns about their child's behavior when they perceived that the problem behavior occurred frequently.
These results suggest that although physicians should remain sensitive to parental distress and its potential effect on both the parent and the child, they should seriously attend to concerns raised by all parents, not just parents experiencing psychosocial distress. In addition, physicians should ask parents about their children's problem behavior and attend to its frequency in addition to asking about whether a particular behavior is viewed as problematic by the parent.
As with all research, the present research was subject to limitations. The sample size of 75 matched physician-parent pairs was smaller than might be desired to sample a large range of behavior problems and increase power to confidently eliminate items as predictors of parental disclosure and physician report of parental disclosure and child psychosocial problems. This lack of power does not weaken the results that were obtained in the present study, but may have contributed to a failure to find additional significant factors related to parental disclosure and physician recognition of disclosure and psychosocial problems. Patients and physicians in a family practice residency training facility may differ from those in community practices. Gilchrist et al31 indicated that patients using community-based family practice training clinics were similar in composition to a national sample of patients visiting family practices. These findings suggest that the patient sample was likely to resemble other community samples. The effect of varying amounts of physician training merits further investigation in the future. The use of parent-completed instruments for the assessment of child behavior problems, rather than clinical interviews, could be seen as a limitation. However, this study was not intended to examine only children who met Diagnostic and Statistical Manual of Mental Disorders–type criteria for psychosocial problems. Rather, it was intended to identify children who were at risk for psychosocial problems, including those who may have had subclinical psychosocial problems. Because the main focus of the research was to explore factors associated with parental disclosure and physician report of disclosure, self-report and screening instruments seemed most appropriate. An objective measure of the actual interactions between parents and physicians would have been useful. Future research may benefit from the use of audiotape or videotape rating to more specifically study the interaction between parents and physicians. This research relied only on reports of the parent. There were no corroborating data concerning the perception of the child by other important adults (eg, teacher, other parent, or close relative). Although corroborating data would have been useful, physicians typically must base their appraisal of a child on the report of the parent accompanying the child to the physician's office.
The results of the present study support previous studies that have indicated that parental disclosure is critical for physician identification of child psychosocial problems.14-16 Because the average length of a well-child examination is 10 to 15 minutes, and acute visits tend to be shorter, the finding that parental disclosure was more important than child or parental psychosocial distress for physician identification of child behavior problems was not surprising.32-33 When parents disclosed psychosocial concerns and had a child with a psychosocial problem, physicians were likely to identify the problem. While physicians were unlikely to report parental disclosure when children did not seem to have psychosocial problems, they also failed to report a substantial percentage of parental disclosures when children did have clinically significant behavior problems. Increasing the efficiency of physicians during office visits is important for improving identification of psychosocial problems without spending inordinate amounts of time with patients who do not require such attention. The results of the present study suggest that physicians need to carefully attend to parental report of concerns about their child's behavior, regardless of whether the parent seems distressed, and ask about the frequency of behavior problems, not just the presence or absence of these problems.
AUTHOR INFORMATION
Accepted for publication November 12, 1998.
| Editor's Note: This study is a reminder that we frequently obtain important information from family members. In this study, a child with problems and a distressed parent (usually the mother) who expressed concern about the child was likely to be recognized by the physician as having psychosocial difficulties. While only half of the children with problems were identified as such by a physician, this is based on a low number of distressed children in the study, and the physician was not necessarily the continuity provider for the patient and family. Perhaps more disconcerting was that more than half of the time the physician did not report psychosocial revelations when parents said they had expressed concerns.
Are you listening to the parents of the children in your office? How do you approach behavioral concerns raised by parents or that you note in the office?—Marjorie A. Bowman, MD, MPA
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Corresponding author: Beth G. Wildman, PhD, Department of Psychology, Kent State University, Kent, OH 44242.
From the Department of Psychology, Kent State University, Kent, Ohio (Dr Wildman and Mr Kizilbash); and the Department of Family Medicine, Northeastern Ohio Universities College of Medicine, Akron (Dr Smucker).
REFERENCES
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1. Costello EJ. Primary care pediatrics and child psychopathology: a review of diagnostic, treatment, and referral practices. Pediatrics. 1986;78:1044-1051.
FREE FULL TEXT
2. Costello EJ. Developments in child psychiatric epidemiology. J Am Acad Child Adolesc Psychiatry. 1989;28:836-841.
ISI
| PUBMED
3. Costello EJ, Costello AJ, Edelbrock C, Burns BJ, Dulcan MK, Brent D. Service utilization and psychiatric diagnosis in pediatric primary care: the role of the gatekeeper. Pediatrics. 1988;82:435-441.
FREE FULL TEXT
4. Costello EJ, Costello AJ, Edelbrock C, Burns BJ, Dulcan MK, Brent D, Janiszewski S. Psychiatric disorders in pediatric primary care. Arch Gen Psychiatry. 1988;45:1107-1116.
FREE FULL TEXT
5. Earls F. Epidemiology and child psychiatry: entering the second phase. Am J Orthopsychiatry. 1989;59:279-283.
ISI
| PUBMED
6. Costello EJ, Janiszewski S. Who gets treated: factors associated with referral in children with psychiatric disorders. Acta Psychiatr Scand. 1990;81:523-529.
ISI
| PUBMED
7. Offord D, Boyle MH, Szatmari P, et al. Ontario Child Health Study: six-month prevalence of disorder and rates of service utilization. Arch Gen Psychiatry. 1987;44:832-836.
FREE FULL TEXT
8. Starfield B, Borkowf S. Physicians' recognition of complaints made by parents about their child's health. Pediatrics. 1969;43:168-172.
FREE FULL TEXT
9. Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: US Dept of Health and Human Services; 1991. DHHS publication 91-50212.
10. Gelfand DM, Teti DM. The effects of maternal depression on children. Clin Psychol Rev. 1990;10:329-353.
FULL TEXT
|
ISI
11. Leaf PJ, Leventhal JM, Forsyth B, Speechley KN. Identification and management of psychosocial and developmental problems in community-based, primary care pediatric practices. Pediatrics. 1992;89:480-485.
FREE FULL TEXT
12. Sharp L, Pantell RH, Murphy LO, Lewis CC. Psychosocial problems during child health supervision visits: eliciting, then what? Pediatrics. 1992;89:619-623.
FREE FULL TEXT
13. Hickson GB, Altemeier WA, O'Conner S. Concerns of mothers seeking care in private pediatric offices: opportunities for expanding services. Pediatrics. 1983;72:619-624.
FREE FULL TEXT
14. Dulcan MK, Costello EJ, Costello AJ, Edelbrock C, Brent D, Janiszewski S. The pediatrician as gatekeeper to mental health care for children: do parents' concerns open the gate? J Am Acad Child Adolesc Psychiatry. 1990;29:453-458
ISI
| PUBMED
15. Lynch TL, Wildman BG, Smucker WD. Parental disclosure of child psychosocial concerns: relationship to physician identification and management. J Fam Pract. 1997;44:273-280.
ISI
| PUBMED
16. Wildman BG, Kinsman AM, Logue E, Dickey D, Smucker WD. Presentation and management of childhood psychosocial problems. J Fam Pract. 1997;44:77-84.
ISI
| PUBMED
17. Christensen A, Phillips S, Russell GE, Johnson SM. Parental characteristics and interactional dysfunction in families with child behavior problems: a preliminary investigation. J Abnorm Child Psychol. 1983;11:153-166.
FULL TEXT
|
ISI
| PUBMED
18. Forehand R, Brody G. The association between parental/personal adjustment and parent-child interactions in a clinic sample. Behav Res Ther. 1985;23:211-212.
FULL TEXT
|
ISI
| PUBMED
19. Griest D, Wells KC, Forehand R. An examination of predictors of maternal perceptions of maladjustment in clinic-referred children. J Abnorm Psychol. 1979;88:277-281.
FULL TEXT
|
ISI
| PUBMED
20. Rickard KM, Forehand R, Wells KC, Griest DL, McMahon RJ. Factors in the referral of children for behavioral treatment: a comparison of mothers of clinic-referred deviant, clinic-referred non-deviant and non-clinic children. Behav Res Ther. 1981;19:201-205.
FULL TEXT
|
ISI
| PUBMED
21. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh L. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-571.
22. Gotlib IH. Depression and general psychopathology in university students. J Abnorm Psychol. 1984;93:19-30.
FULL TEXT
|
ISI
| PUBMED
23. Cavanaugh SV. The prevalence of emotional and cognitive dysfunction in a general medical population: using the MMSE, GHQ, and BDI. Gen Hosp Psychiatry. 1983;5:15-24.
FULL TEXT
|
ISI
| PUBMED
24. Monroe SM, Imhoff DF, Wise BD, Harris JE. Prediction of psychological symptoms under high-risk psychosocial circumstances: life events, social support, and symptom specificity. J Abnorm Psychol. 1983;92:338-350.
FULL TEXT
|
ISI
| PUBMED
25. Baker LL, Jessup BA. The psychophysiology of affective verbal and visual information processing in depression. Cognit Ther Res. 1980;4:135-148.
FULL TEXT
|
ISI
26. Kendall PC, Hollon D, Beck AT, Hammen CL, Ingram RE. Issues and recommendations regarding use of the Beck Depression Inventory. Cognit Ther Res. 1987;11:289-299.
27. Eyeberg SM, Ross AN. Assessment of child behavior problems: the validation of a new inventory. J Clin Child Psychol. 1978;7:113-116.
ISI
28. Boggs SR, Eyberg S, Reynolds LA. Concurrent validity of the Eyberg Child Behavior Inventory. J Clin Child Psychol. 1990;19:75-78.
FULL TEXT
|
ISI
29. Goldberg ID, Roghmann KJ, McInerny TK, Burke JD Jr. Mental health problems among children seen in pediatric practice: prevalence and management. Pediatrics. 1984;73:278-293.
FREE FULL TEXT
30. Eyberg S. Parent and teacher behavior inventories for the assessment of conduct problem behaviors in children. In: VandeCreek L, Jackson TL, eds. Innovations in Clinical Practice: A Source Book. Vol 11. Sarasota, Fla: Professional Resource Press; 1992:261-270.
31. Gilchrist V, Miller RS, Gillanders WR. Does family practice at residency teaching sites reflect community practice? J Fam Pract. 1993;37:555-563.
ISI
| PUBMED
32. Korsch BM, Negrete VF, Mercer AS, Freemon BM. How comprehensive are well child visits? AJDC. 1971;122:483-488.
33. Reisinger KS, Bires JA. Anticipatory guidance in pediatric practice. Pediatrics. 1980;66:889-892.
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