Screening Children and Adolescents (5–18 Years)

Screening Children and Adolescents (5–18 Years)
Screening for child and adolescent behavioral disorders using the Pediatric Symptom Checklist (PSC) is widely used in many medical practices and Medicaid programs. The current literature documents the ability of this brief, one-page instrument to identify children in need of further behavioral evaluation. Unfortunately, there are no randomized, controlled studies that document outcomes on screened individuals or groups, compared with populations not screened. PSC screening is classified “targeted” rather than “general” because the studies needed to provide a firmer evidence base have not been done.

A. Screening for Evidence of Behavioral Disorder

The PSC is a brief, one-page, 35-question instrument designed for use by parents in the doctor’s waiting room. The questionnaire is designed to detect behavioral and psychosocial problems in children from 2 to 16 years of age, and it has been used effectively in persons up to 18 years of age (Bernal et al., 2000). Each of the questions can be answered with a “never,” sometimes,” or “often,” with scores of 0, 1, or 2, respectively, attributed to each answer. Scores of 24, 28, or higher, depending on the age of the child, are considered indicative of a possible behavioral or psychosocial problem and will warrant further exploration by the clinician (Jellinek & Murphy, 1999).

The PSC has been suggested as a tool for universal use with children 2 to 16 years of age to screen for behavioral and psychosocial problems (Jellinek & Murphy, 1988; Walker, LaGrone, & Atkinson, 1989; Murphy, Arnett, Bishop, Jellinek, & Reede, 1992; Jellinek & Murphy, 1999, Gardner, 2002; Jellinek et al., 1999). In use since the 1970s, the PSC has been tested and used in tens of thousands of children; scored well in a test of its usefulness to the Medicaidsponsored Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program (Murphy et al., 1996); and is used in several States in the context of their EPSDT programming (Jellinek & Murphy, 1999; Bernal et al., 2000; Gardner, Kelleher, & Pajer, 2002).

The PSC has been found to be acceptable to parents, regardless of socioeconomic status or ethnicity, and to clinicians and clinic office staff (Murphy et al., 1992; Murphy, Reede, Jellinek, & Bishop 1992; Jellinek et al., 1999; Navon, Nelson, Pagano, & Murphy, 2001). It has been validated against more elaborate classification instruments—the Child Behavior Checklist (CBCL) and the Clinician’s Global Assessment Scale (CGAS (Walker et al., 1989; Jellinek & Murphy, 1999). It also routinely generates prevalence rates for pediatric psychosocial and behavioral disorders of approximately 12 percent, which is consistent with other estimates of pediatric behavioral and psychosocial disorders (Jellinek & Murphy, 1999; Jellinek, 1999). The expected increase in psychosocial dysfunction with lower socioeconomic class (Jellinek, Little, Murphy, & Pagano, 1995) and the expected correlation with maternal psychological distress and marital adjustment (Sanger, MacLean, & Van Slyke, 1992) have been clearly documented.

The primary outcome measure noted in the PSC literature has been the percentage of children referred for behavioral or psychosocial evaluation and treatment. This rate of referral has dramatically increased with the introduction of the PSC in every study where this measure has been reported (Navon et al., 2001). In one study, the referral rate increased from 1.5 percent before implementation of the PSC to 12 percent, then dropped back to 2 percent after the PSC screening was discontinued (Murphy et al., 1992). This review found no studies that address the behavioral and psychosocial benefits to the children screened or costs associated with referral of false-positive cases.

One study published in 2000 (Bernal et al., 2000) reported average log costs for health and psychiatric care for all children studied at $393 per year, and costs of those with anxious, depressed symptoms at $805 per year. Chronically ill children showed the highest health care costs, with average log costs of $1,138 per year. Psychosocial dysfunction was associated with higher costs. Unfortunately, this study did not explore whether detection and treatment of the psychosocial dysfunction could lower these costs. With a documented minimum sensitivity (accurately detecting true “positives” or those with the illness) of 80 percent, and a specificity (detecting those without disease) of 68 percent or better (Jellinek et al., 1988; Jellinek & Murphy, 1999), this screening instrument may miss up to 20 percent of children who have serious problems, and refer up to 32 percent of well children to diagnostic interviews that prove negative for any treatable behavioral or psychosocial behavior. Although these efficacy statistics are within acceptable ranges for screening instruments, they do speak to costs of program implementation that need to be considered. Like virtually all other screening programs, little or no benefit will accrue without follow-up treatment for those found to be in need of such treatment. Owing to the research findings, the PSC may be considered a “targeted” service for use in health care delivery settings with providers and health care systems wishing to use it.

The available literature leaves unanswered the possible use of the PSC when the primary care practitioner suspects a significant behavioral problem but does not have enough information to confirm or deny this impression. For such cases, health care systems may wish to make this instrument available to providers for selective use, at their discretion.

The PSC, along with articles describing its proper use on the Pediatric Development and Behavior Web site, is available at www.dbpeds.org/handouts/ (Jellinek & Murphy, 1999) under “screening.” It should be used without modification, other than for translation when working with non- English-speaking families.

The PSC consists of 35 very brief statements to which the parent responds “never,” “sometimes,” or “often.” Presented on a single page with check-off boxes, sample statements include: “Complains of aches/pains; tires easily, little energy; has trouble with a teacher; acts as if driven by a motor … .” The responses are graded on a zero-to-two scale. Depending on age, a score of 24, 28, or greater is considered indicative of significant psychosocial impairment (Jellinek & Murphy, 1999).

Summary: Children and Adolescents 5–18 Years

Screening for potential child and adolescent behavioral disorders using the PSC is widely used in medical practices and Medicaid programs. Because of its low burden (brief), ease of use, wide applicability, and validity, the literature supports its use by health plans with all children in a health care system. In this report, such screening is classified as a “targeted” service rather than “general” because no randomized controlled trials that could document outcomes have been attempted.

After The Disaster: A Children’s Mental Health Checklist

After The Disaster: A Children’s Mental Health Checklist

Disasters can be particularly traumatic to children. Sometimes, it can be difficult to determine the extent of the psychological trauma, and whether or not professional mental health services are indicated. This checklist is one way to assess a child’s mental health status.

Add up the pluses and minuses to obtain a final score. If the child scores more than 35, it is suggested you seek a mental health consultation.

Has the child had more than one major stress within a year BEFORE this disaster, such as a death in the family, a molestation, a major physical illness or divorce? If yes: +5


Does the child have a network of supportive, caring persons who continue to relate to him daily? If yes: -10


Has the child had to move out of his house because of the disaster? If yes: +5


Was there reliable housing within one week of the earthquake with resumption of the usual household members living together? If yes: -10


Is the child showing severe disobedience or delinquency? If yes: +5
Is the child showing any of the following as NEW behaviors for more than three weeks after the disaster?

Nightly states of terror? +5


Waking from dreams confused or in a sweat? +5


Difficulty concentrating? +5


Extreme irritability? +5


Loss of previous achievements in toilet or speech? +5


Onset of stuttering or lisping? +5


Persistent severe anxiety or phobias? +5


Obstinacy? +5


New or exaggerated fears? +5


Rituals or compulsions? +5


Severe clinging to adults? +5


Inability to fall asleep or stay asleep? +5


Startling at any reminder of the disaster? +5


Loss of ambition for the future? +5


Loss of pleasure in usual activities? +5


Loss of curiosity? +5


Persistent sadness or crying? +5


Persistent headaches or stomach aches? +5


Hypochondria? +5


Has anyone in the child’s immediate family been killed or severely injured in the disaster (including severe injury to the child)? +15
Note: Preoccupation with death, unusual accident proneness or suicidal threats are reasons for immediate consultations. It is also recommended that any child who has been seriously injured or who has lost a parent, sibling or caregiver by death, have a psychological evaluation and/or brief therapy.

Note: This checklist was developed under the auspices of Project COPE, a federal funded (FEMA) crisis counseling program activated in Santa Cruz, California, in response to the October 17, 1989 Loma Prieta Earthquake. The project provided individual, family and group counseling, agency debriefing services and a school intervention program. Over the course of 16 months, the project provided services to more than 25,000 individuals. Peter J. Spofford, M.S. served as Project COPE Director.

Depression and Mood Disorders

Depression and Mood Disorders
The Prevalence of Major Depression and Mood Disorders in Suicide

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Depression and Mood Disorders CEUs for MFTs, LCSWs, LPCs, and Social Workers
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.

Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.

Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.

Building Self-Esteem in Children

Building Self-Esteem in Children

Most parents have heard that "an ounce of prevention is worth a pound of cure" and it's especially true with self-esteem in children. All children need love and appreciation and thrive on positive attention. Yet, how often do parents forget to use words of encouragement such as, "that's right," "wonderful," or "good job"? No matter the age of children or adolescents, good parent-child communication is essential for raising children with self-esteem and confidence.

Self-esteem is an indicator of good mental health. It is how we feel about ourselves. Poor self-esteem is nothing to be blamed for, ashamed of, or embarrassed about. Some self-doubt, particularly during adolescence, is normal—even healthy-but poor self—esteem should not be ignored. In some instances, it can be a symptom of a mental health disorder or emotional disturbance.

Parents can play important roles in helping their children feel better about themselves and developing greater confidence. Doing this is important because children with good self-esteem:

Act independently
Assume responsibility
Take pride in their accomplishments
Tolerate frustration
Handle peer pressure appropriately
Attempt new tasks and challenges
Handle positive and negative emotions
Offer assistance to others
Words and actions have great impact on the confidence of children, and children, including adolescents, remember the positive statements parents and caregivers say to them. Phrases such as "I like the way you…" or "You are improving at…" or "I appreciate the way you…" should be used on a daily basis. Parents also can smile, nod, wink, pat on the back, or hug a child to show attention and appreciation.

What else can parents do?

Be generous with praise. Parents must develop the habit of looking for situations in which children are doing good jobs, displaying talents, or demonstrating positive character traits. Remember to praise children for jobs well done and for effort.
Teach positive self-statements. It is important for parents to redirect children's inaccurate or negative beliefs about themselves and to teach them how to think in positive ways.
Avoid criticism that takes the form of ridicule or shame. Blame and negative judgments are at the core of poor self-esteem and can lead to emotional disorders.
Teach children about decisionmaking and to recognize when they have made good decisions. Let them "own" their problems. If they solve them, they gain confidence in themselves. If you solve them, they'll remain dependent on you. Take the time to answer questions. Help children think of alternative options.
Show children that you can laugh at yourself. Show them that life doesn't need to be serious all the time and that some teasing is all in fun. Your sense of humor is important for their well-being.
The Caring for Every Child's Mental Health Campaign Campaign is part of The Comprehensive Community Mental Health Services Program for Children and Their Families of the Federal Center for Mental Health Services. Parents and caregivers who wish to learn more about mental well-being in children should call 1-800-789-2647 (toll-free) or visit mentalhealth.samhsa.gov/child/ to download a free publications catalog (Order No. CA-0000). The Federal Center for Mental Health Services is an agency of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

substance abuse ceus

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substance abuse ceus

Alcoholism and Substance Abuse Dependency (15 hours)
Description CH 1-Definitions
CH 2-History
CH 3-DSM Criteria
CH 4-Types of Substance Abuse
CH 5-Prescription Drug Addiction and Dependence
CH 6-Demographic Characteristics
CH 7-Substance Abuse Treatments and Outcomes


Become familiar with clinical and statistical information regarding substance abuse history, DSM criteria, types of abuse, demographic characteristics, treatment, and outcomes.
Define substance abuse and identify its effects.
Become familiar with the medical aspects of alcohol abuse/dependence and other types of chemical dependency.
Apply current theories of the etiology of substance abuse.
Recognize the role of persons and systems that support or compound the abuse.
Become familiar with the major treatment approaches to alcoholism and chemical dependency.
Learn the national legal aspects of substance abuse.
Obtain knowledge of certain populations at risk with regard to substance abuse.
Access community resources offering assessment, treatment and follow-up for the abuser and family.
Learn the process of referring affected persons.

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