I
·
DEVELOPMENT AND BEHAVIOR: OLDER CHILDREN AND ADOLESCENTS
0031-3955/92 $0.00
+ .20
BEHAVIORAL ASSESSMENT OF CHILDREN AND ADOLESCENTS Jack W. Finney, PhD, and Mark D. Weist, PhD
Health encompasses physiologic, psychologic, and social aspects of children's development. From a comprehensive definition of health comes a broad range of goals for pediatric health supervision, including monitoring of children's behavioral development and parents' concerns about their children's behavior problems. 4 A regular schedule of visits for health supervision and periodic visits for acute care provide many opportunities for the assessment of children's behavioral status. Parents and children also may identify concerns about their children's behavior or development during these visits,.' and their concerns may indicate the need for further assessment. By screening, interviewing, and observing children and their parents, primary care clinicians can complete behavioral assessments to determine whether parents and children may benefit from further assessment or therapy for behavioral and development problems. Primary care clinicians have been shown to play an important role in facilitating receipt of mental health services!! as well as to, fail to identify numerous children who may benefit from these services. 12 It therefore is essential that behavioral assessment be better incorporated into primary health care practice. Unlike most mental health professionals, the primary care clinician has opportunities to observe normally developing children throughout childhood and adolescence. Other contacts between the child and physician occur during visits for acute illnesses and injuries. These multiple contacts provide a unique context for behavioral assessment. A series of behavioral and development screenings and assessments can be completed to help assure parents that their children are growing, developing, and behaving within normal (optimal) limits. Alternatively, clinicians may identify potential areas of concern based on a
From the Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, Virginia (JWF); and the Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland (MDW)
PEDIATRIC CLINICS OF NORTH AMERICA VOLUME 39 • NUMBER 3 • JUNE 1992
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parent's worries, fears, and expectations; a parent's apparent capabilities; and a child's present behavioral patterns or characteristics. Ideally, child health supervision should result in the identification of "problems" before they occur or at least before the child's behavior problems are severe or the parent's reactions are intense. Practically, however, early identification of problems and interventions designed to change the course of the early problems will only be a reality when better predictors of future behavior problems are developed. Few studies have identified early predictors, and even fewer have followed children in longitudinal designs of sufficient duration to identify early childhood predictors of later problems of adolescence. A recent exception is a study that found that poor peer relations in early elementary school portend adjustment problems in adolescence, including juvenile delinquency, substance abuse, and poor academic performance. 4 ' Because of limitations inherent in the primary health care system, screening instruments, interviewing, and· parent and child monitoring of behavior are the most feasible assessment techniques for ongoing assessment of the child's behavioral and developmental status. Screening devices of widely varying reliability and validity often are used in primary care, and the inadequacies of some of these have been discussedY 30 Screening, however, can facilitate interviewing. The behavioral interview can be based on screening results, in which the clinician probes for additional information about "red flags" identified by a screening instrument and for other problem areas not covered or perhaps misidentified by a screening device. Information derived from the behavioral interview can indicate important child and parent behaviors that can be monitored by the parent in the home and other natural settings to provide a more objective description of the problem situations. Primary care assessment often requires a reliance on parent and child reports of behavior problems. Observation of parent or child behavior is often time-limited and setting specific (i.e., in the office). Most often, only information derived from interviews is available for the frequency, duration, and intensity of problems, situational characteristics associated with the problem, reactions of parents and others to the child's behavior, and other information relevant for selecting and implementing interventions. More detailed assessments of problem behaviors are often difficult to accomplish in the course of routine primary care, and thus, one weakness of behavioral assessment in primary care settings is that imprecise or incorrect assumptions identified through screening and interviewing may lead to ineffective, or at times, inappropriate treatment recommendations. 49 Research on behavioral and other psychological assessment has shown that a number of problem behaviors that have been identified for intervention often are based on inappropriate assumptions or assessments. 48 . 49 Careful attention to the consistency of information obtained, the use of multiple methods and sources, and the use of reliable and valid assessment practices can assist in avoiding mistaken problem labeling, advice giving, or referral. 38.41
THE FUNCTIONS OF BEHAVIORAL ASSESSMENT IN PRIMARY CARE
Hawkins 26 has identified five functions of behavioral assessment that are relevant for primary care-based assessment (Table 1). Initially, the clinician provides screening to help him or her decide whether a child or family has a problem. If a problem is identified, the clinician must then decide whether further assessment and therapy can be accomplished in primary care visits or
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Table 1. FIVE FUNCTIONS OF ASSESSMENT FOR CHILDREN AND FAMILIES Screening and General Disposition What are the child's problems? Are the child's problems appropriate for assessment and intervention in primary care? If not, where should the child be referred? If yes, what further assessments are needed? Definition and Extent of the Problem What are the specific behavioral, developmental, and emotional problem(s) and parental concerns? What are the details about the problem (frequency, intensity, situations, consequences, corollary behaviors)? What are possible causes and correlates related to the problem? What do these causes and correlates suggest about possible interventions? Assessment for Designing an Intervention What are specific behavioral objectives for the child and parent? How do parents currently respond to the child's problem behavior? How might their responses be changed? What can the child be taught to enable him or her to avoid problem behaviors? What resources are available to the family for helping with their current situation? Monitoring of Progress How often do the problems occur before and after intervention by the health care provider? Are the changes in behavior clinically (socially) significant and sufficient, or is there a continued need for intervention? Who should provide the additional intervention, the health care provider or a mental health profeSSional? Follow-up Are the problems still present at a future office visit? Have the behavioral changes accomplished earlier lasted? Do the changes continue to be sufficient for making the child, parent, and family successful? Are there new behavior problems and concerns that require additional assessment? Note: The functions of assessment were derived from Hawkins RP: The functions of assessment: Implications for the selection and development of devices for assessing repertoires in clinical, educational. and other settings. J Appl Behav Anal 12:501-516, 1979.
whether referral to a mental health professional would be best. 44 Further details about the specific child, parent, and family problems are needed if the primary care clinician chooses to complete assessment and introduce intervention. In planning for an intervention, the clinician needs to help parents and children establish behavioral objectives, for example, assisting parents in identifying how often a problem may occur before disciplinary actions should be taken. Additional detail about current parenting approaches and ways children can be encouraged to develop new patterns of behavior can be assessed. Once a recommendation is given, the clinician needs to follow the parent and child to determine whether the problem is getting better or worse or staying the same. Determining whether any behavioral improvements are clinically relevant (socially valid]5. 51) or whether new behavioral concerns have occurred informs the clinician about recommending additional assessment or treatment services. At later follow-up health care visits, the clinician can continue to check on the child's and parents' progress to assess the child's development over time, provide any indicated assessment or treatment services, or refer to appropriate mental health professionals.
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A STRUCTURE FOR BEHAVIORAL ASSESSMENT IN PRIMARY CARE
Parents often can complete behavioral questionnaires and screening devices before the encounter with the primary care clinician. Parents obtain information for themselves by completing screening instruments: they learn, for example, that behavioral topics as well as medical and health topics are appropriate for discussion during primary care visits. 16
Behavioral Interview
The behavioral interview can be guided by the parents' responses to screening questionnaires. Remarks about the child's strengths (e.g., plays well independently, completes home responsibilities) can be elicited from parents in conjunction with probes for further details about areas that are identified as problematic. When parents indicate in an interview the problems of most concern, the clinician must obtain further behavioral information to guide the assessment and treatment process. The timing of this additional assessment varies. Some clinicians have some flexibility in schedules that allows for extended discussion during the visit; others need to schedule later appointments to continue the assessment. 25 A number of questions can be used to prompt parents to discuss their children's behavior. Open ended questions are helpful for some parents because they provide a general invitation for parents to mention their concerns. Others may respond best to specific questions about common child behaviors, family living patterns, school performance and activities, and parent-child relationships. Health care clinicians usually have standard questions that they use to generate discussion with parents; if these questions do not encourage interaction with parents, clinicians should continue revising their usual practices to facilitate open communication during visits. 23
Observation During the Visit
Despite the limitations of brief observations in an "unnatural" setting, observation of parent and child interactions can provide information about current parent management techniques. Obvious examples are spankings, frequent scoldings and warnings, parental indifference to the child's behavior in the examination room, or parental inattention to the child's questions. More subtle but perhaps important are facial grimaces, finger shakes as warnings, and noticeable emotional exasperation at what are often common child misbehaviors in a crowded examination room. With older children, parents may be prone to interrupting the children who are asking or answering questions. Frequent interruptions may indicate a parent who is rigid in his or her perceptions of how older children should participate during health care visits. Despite its limitations, careful observation of parent and child behavior during the appointment can assist in determining the presence of behavioral problems or concerns, family problems that may be helped by a therapist or school counselor, and· the extent of management suggestions that may be helpful for the family.
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Monitoring by Parent and Child
An additional source of information can come from the parents and children. The primary care clinician can ask for more details about identified problems by teaching the parent to keep records of child and parent behavior at home. The parent can be instructed to note the frequency, duration, or intensity of specific behaviors, antecedents and consequences of the behaviors, and situational variables. The child also can be asked to record his or her own behaviors that are problematic and parent behaviors that the child thinks may be relevant as well as successful instances of behavior in a usually problematic situation. A structure for recording information should be provided: calendars, notebooks, diaries, or simple data sheets with days and columns can be provided or their purchase recommended (Table 2). Behavioral data, when reviewed with the parent and child at a later appointment, can help to determine the extent of problem situations and can provide the necessary information for implementing an intervention and assessing its effects or can be used for referral for services from mental health professionals. IS In addition to getting more detail about the extent of behavior problems, Table 2. EXAMPLE OF A PARENT MONITORING FORM Child's Name: _ _ _ _ _ _ _ _ _ _ __
BEHAVIOR Makes bed w/out remind
Dressed on time Home on time Hits sister
Sneaks snacks Father nags Mother nags
MON
TUES
WED
Week 01: _ _ __
THUR
FRI
Recorder: _ _ __
SAT
SUN
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self-monitoring can provide information about the family's readiness to work on a clinical problem. A parent's or child's failure to record information regularly may signal the family's lack of structure and routine or the parent's or child's lack of motivation to pursue solutions for the previously identified concerns. Records, whether detailed or sketchy, provide a context for discussing the family's functioning since the last appointment. CONTENT OF ASSESSMENT
As the child ages, the content for behavioral assessment shifts from screening for common developmental milestones to more complex developmental, social, and behavioral achievements and problems. 2• Increasing interaction with peers and adults is required as the child encounters a wider range of social situations such as school, recreational activities, and shopping. A number of assessment and screening inventories have been developed to cover a wide range of child behavior (Table 3). Uses for these and other inventories have been discussed at length. 19. 34, 36. 37 Social Relationships
When the primary care clinician incorporates behavioral assessment into health care, discussion of the child's social relationships and developmental levels becomes a critical part of the assessment. Parent-child interactions form the basic socialization process for infants and young children. All physical needs are mediated by the parent, and most social needs are initially mediated by the parent. Thus, it is important for clinicians to assess the parent's knowledge of and responsiveness to an infant's signs of physical and emotional needs lO and to assess continuously the development of the child's social communication abilities. Standardized observational systems have been developed to assess, for Table 3. ASSESSMENT AND SCREENING INVENTORIES FOR PRIMARY CARE SETTINGS Developmental Screening Brazelton Neonatal Assessment Scale? Denver Developmental Screening Test (Revised)21 Denver Prescreening Developmental Questionnaire2' Kansas Infant Development Scale'? Assessment of Home Situations Relevant to Behavior and Development HOME Inventory Scale" Home Screening Questionnaire (HSQ)2° Behavior Problems Brief Symptom Checklist28 40 Eyberg Child Behavior Inventory14 Child Behavior Checklist ' - 3 Connors Parent Symptom Rating Scale 24 SchoolPerlormance Aggregate Neurobehavioral Student Health and Education Review (ANSER) System 31 Pediatric Examination of Educational Readiness (PEER)32,35 Pediatric Early Elementary Examination (PEEX)34 Pediatric Examination of Educational Readiness at Middle Childhood (PEERAMID)33
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example, eye contact, method of holding the infant, and other physical interaction characteristics of the parent and child,46 but extensive observational data are unwieldy to obtain in a primary care setting. Therefore, the clinician must obtain as much information about the parents' care-giving, responsiveness to the child, and other features of parenting skills through interviews or questionnaires. For older children, social relationships can be assessed by a standardized behavioral questionnaire (e.g., the Child Behavior ChecklisP). School information on the child's performance and participation in activities can provide additional information about the child's development in this area. 30 Developmental Considerations
To be effective, child behavioral assessment and the advice provided based on the assessment must be consonant with the developmental level of the child. s. 42 Many developmental skills occur in a relatively orderly fashion: many children creep, crawl, cruise, and then finally walk, each advancement in skill corresponding to the physical and cognitive development of the child. Training before the child has developed the requisite physical development often is unsuccessful or at least unpleasant for the child, the parent, or both. For example, children are unlikely to attain independence in tOileting until the bladder, musculoskeletal system, and nervous system have developed sufficiently for bladder control to be physically and cognitively possible. Easily observed behaviors serve as indicators of biologiC and psychological maturation. For example, numerous toilet training readiness criteria (e.g., bladder control, finger and hand coordination, responsiveness to parent instructions) have been identified. 5 The success of this approach supports the assumption that the readiness behaviors are directly related to the important physical and cognitive developmental characteristics needed for achieving independent toileting. The primary care clinician can assess through a combination of interview and observation the child's performance on these criteria and counsel parents according to the child's attainments about the timing and techniques of a range of skills once similar developmental readiness skills have been elaborated. Older children and adolescents also must be monitored for development of independence and responsibility. Discussion of the parent's perceptions of the older child's or adolescent's need for parental or other adult supervision could aid in helping parents to decide, for example, when it would be appropriate to leave a child at home alone, when to expect a child to perform a number of regular home chores, and when to allow a child to date or attend an unsupervised party. Assessment of adolescent development has received limited attention; however, key areas for assessment include perceived academic and social competence, performance in school, success with peer relations (e.g., dating), planning for college or a vocation, and pressures to use alcohol or other drugs. The health care clinician can begin with these issues in his or her assessment of the adolescent when behavioral issues are addressed. Each clinician must develop comfort and competence in assessing the difficult dilemmas faced by adolescents and their parents and in advice that is offered to these families. Assessment of Reactions to Children's Illness Behavior
Primary care clinicians are in a unique position to monitor the interaction of illnesses with social and environmental events that can result in new or
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sustained illness behavior patterns in children. The child who has repeated ear infections with related hearing loss often can appear to be "deaf" to parent instructions long after fluid is no longer present in the ear canal. Similarly, the child who has flu-like symptoms may persist in "sick" behavior long after fever, chills, vomiting, diarrhea, and other acute symptoms have disappeared. Is the child still sick? Perhaps, but often changes in parental expectations, attention to sick behavior, and avoidance of undesired activities (e.g., school attendance, home chores) can result in prolonged illness behavior.47,0 The primary care clinician must assess the likely changes in parental management that may account for prolonged sick behavior and suggest, after complete medical and behavioral assessment, possible changes in parent management style, behavior, and attitudes that foster renewed health and activities in the child." THE VALUE OF BEHAVIORAL ASSESSMENT IN PRIMARY CARE
The incorporation of behavioral assessment in primary care results in significant advances in addressing children's behavioral and developmental problems. Primary care clinicians can obtain more detailed information about parent concerns, child behavior, and environmental and social interactions using screening questionnaires, conducting a behavioral interview, and having parents and children monitor their behavior in home and school settings. Such assessment data provide the basis for determining the severity of problems, the types of interventions likely to be effective in resolution of the behavior problems, and the need for referral for mental health services. Primary care clinicians can be considered a "first line of defense" for identification and remediation of common behavioral and developmental problems of childhood. As the gatekeepers of mental health care,l1 primary care clinicians need to incorporate behavioral assessment. Through repeated monitoring of children, the clinician can determine areas for which parents and children will benefit from more intensive assessment and treatment in primary care. Both behavioral assessment and treatment services require changes in primary health care, including training in the theory and practice of psychological assessment and treatment, restructuring of pediatric practice to include longer and repeated appointments for these services, and appropriate fees for these new levels of services. These changes provide an improved health care system that is responsive to all aspects of children's health.
References
J Consult CIin Psychol 46:478-488, 1987 Achenbach T, Edelbrock C: Behavioral problems and competencies reported by parents of normal and disturbed children aged four through sixteen. Monogr Soc Res Child Dev 46:1-81, 1981 Achenbach T, Edelbrock C: Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington, VT, University of Vermont, 1983 American Academy of Pediatrics: Guidelines for Health Supervision, ed 2. Elk Grove Village, IL, American Academy of Pediatrics, 1988 Azrin NH, Foxx RM: Toilet training in less than a day. New York, Simon & Schuster, 1974
1. Achenbach T: The Child Behavior Profile: I. Boys aged 6-11.
2. 3. 4. 5.
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6. Bradley RH, Campbell BM: Pediatric usefulness of home assessment. In Camp B (ed): Advances in Behavioral Pediatrics, vol 2. Greenwich, CT, JAI Press, 1981, pp 61-80 7. Brazelton TB: Neonatal Behavioral Assessment Scale. London, Heinemann, 1973 8. Campbell SB: Developmental considerations. In Ollendick TH, Hersen M (eds): Handbook of Child Psychopathology, ed 2. New York, Plenum, 1989, pp 5-28 9. Christophersen ER: Incorporating behavioral pediatrics into primary care. Pediatr Clin North Am 29261-296, 1982 10. Christophersen ER: The Babyowner's Manual. Kansas City, MO, Westport Publishers, 1989 11. Costello EJ, Burns BI, Costello AI, et al: Service utilization and psychiatric diagnosis in pediatric primary care: The role of the gatekeeper. Pediatrics 82:435-441, 1988 12. Costello EI, Costello AI, Edelbrock C, et al: The new hidden morbidity: Psychopathology in pediatric primary care. Pediatrics 82:415-424, 1988 13. Edwards Me, Finney JW, Bonner M: Matching treatment with recurrent abdominal pain symptoms: An evaluation of dietary fiber and relaxation treatments. Behavior Therapy 22:257-267, 1991 14. Eyberg SM, Ross AW: Assessment of child behavior problems: The validation of a new inventory. J Clin Child Psychol 7:112-116, 1978 15. Finney JW: On further development of the concept of social validity. J Appl Behav Anal 24:526-530, 1991 16. Finney JW, Brophy q, Friman pe, et al: Promoting parent-provider interaction during young children's health supervision visits. J Appl Behav Anal 23:207-213, 1990 17. Finney JW, Lemanek KL, Cataldo MF, et al: Peciiatric psychology in primary health care: Brief targeted therapy for recurrent abdominal pain. Behavior Therapy 20:283291, 1989 18. Finney JW, Riley AW, Cataldo MF: Psychology in primary health care: Effects of brief targeted therapy on children's medical care utilization. J Pediatr Psychol 16:447461, 1991 19. Frankenburg WK: Infant and preschool developmental screening. In Levine MD, Carey AC, Crocker AC, et al (eds): Developmental-Behavioral Pediatrics. Philadelphia, W.B. Saunders, 1983, pp 927-937 20. Frankenburg WK, Coons CE: Home Screening Questionnaire: Its validity in assessing home environment. J Pediatr 108:624-626, 1986 21. Frankenburg WK, Fandal AW, SciariJIo W, et al: The newly abbreviated and revised Denver Developmental Screening Test. J Pediatr 99:995-999, 1981 22. Frankenburg WK, van Doornick WD, Liddell TN, et al: The Denver Pre screening Developmental Questionnaire (PDQ). Pediatrics 57:744-753, 1976 23. Golden AS, Carlson CG, Hagen JL: The Art of Teaching Primary Care. New York, Springer, 1982 24. Goyette e, Conners e, Ulrich R: Normative data on revised Conners Parent and Teacher Rating Scales. J Abnorm Child Psychol 6:221-236, 1978 25. Green M: Coming of age in general pediatrics. Pediatrics 72:275-282, 1983 26. Hawkins RP: The functions of assessment: Implications for the selection and development of devices for assessing repertoires in clinical, educational, and other settings. J Appl Behav Anal 12:501-516, 1979 27. Holmes G, Hassanein R: The KIDS chart: A simple, reliable infant development screening tool. Am J Dis Child 136:997-1001, 1982 28. Jellinek MS, Murphy JM: Screening for psychosocial disorders in pediatric practice. Am J Dis Child 142:1153-1157, 1988 29. Johnson JH, Goldman J (eds): Developmental Assessment in Clinical Child Psychology. New York, Pergamon, 1990 30. Landman GB: Preventing school failure: The physician as child advocate. Pediatr Clin North Am 33:935-953, 1986 31. Levine MD: The ANSER system. Cambridge, MA, Educators Publishing Service, 1980 32. Levine MD: The Pediatric Examination of Educational Readiness (PEER). Cambridge, MA, Educators Publishing Service, 1982 33. Levine MD: The Pediatric Examination of Educational Readiness at Middle Childhood (PEERAMID). Cambridge, MA, Educators Publishing Service, 1982
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34. Levine MD: The developmental assessment of the school age child. In Levine MD, Carey WB, Crocker AC, et al (eds): Developmental-Behavioral Pediatrics. Philadelphia, W.B. Saunders, 1983, pp 938-947 35. Levine MD, Oberklaid F, Ferb TE, et al: The pediatric examination of educational readiness: Validation of an extended observation procedure. Pediatrics 66:341-349, 1980 36. Liptak GS, Chamberlin RW: Clinical assessment of behavioral performance or adjustment. In Levine MD, Carey WB, Crocker AC, et al (eds): DevelopmentalBehavioral Pediatrics. Philadelphia, W.B. Saunders, 1992, pp 916-922 37. MacMahon RJ: Behavioral checklists and rating scales. In Ollendick TH, Hersen M (eds): Child Behavioral Assessment: Principles and Procedures. New York, Pergamon, 1984, pp 80-105 38. Mash EJ, Terdal LG (eds): Behavioral Assessment of Childhood Disorders: Selected Core Disorders, ed 2. New York, Guilford, 1988 39. Meisels SJ: Can developmental screening tests identify children who are developmentally at risk? Pediatrics 83:578-585, 1989 40. Murphy JM, JeIlinek M, Milinsky S: The Pediatric Symptom Checklist: Validation in the real world of middle school. J Pediatr Psychol 14:629-639, 1989 41. Ollendick TH, Hersen M: An overview of child behavioral assessment. In Ollendick TH, Hersen M (eds): Child Behavioral Assessment: Principles and Procedures. New York, Pergamon, 1984, pp 3-19 42. Ollendick TH, King NJ: Developmental factors in child behavioral assessment. In Martin PR (ed): Handbook of Behavior Therapy and Psychological Science: An Integrative Approach. New York, Pergamon, 1991, pp 51-72 43. Ollendick TH, Weist MD, Borden MC, et al: Sociometric status and academic, behavioral, and psychological adjustment: A 5-year longitudinal study. J Consult Clin Psychol, in press 44. Phillips S, Sarles RM, Friedman SB: Consultation and referral: When, why, and how. Pediatr Ann 9:36-45, 1980 45. Starfield B, Borkow S: Physicians' recognition of complaints made by parents about their children's health. Pediatrics 43:168-172, 1969 46. Vietze PM, Falsey S, O'Connor S: Newborn behavioral and interactional characteristics of nonorganic failure-to-thrive infants. In Field T, Goldberg S, Stern D, et al (eds): Interactions of High Risk Infants and Children. New York, Academic Press, 1980, pp 5-23 47. Walker LS, Zeman JL: Parental response to child illness behavior. J Pediatric Psychol 17:49-71, 1992 48. Weist MD, Ollendick TH: Toward empirically valid target selection with children: The case of assertiveness. Behav Modif 15:213-277, 1991 49. Weist MD, Ollendick TH, Finney JW: Toward the empirical validation of treatment targets in children. Clinical Psychology Review 11:515-538, 1991 50. Whitehead WE: Pediatric gastrointestinal disorders. In Krasnegor NA, Arasteh JD, Cataldo MF (eds): Child Health Behavior: A Behavioral Pediatrics Perspective. New York, Wiley, 1986, pp 537-555 51. Wolf MM: Social validity: The case for subjective measurement or how applied behavior analysiS is finding its heart. J Appl Behav Anal 11:203-214, 1978
Address reprint requests to Jack W. Finney, PhD Department of Psychology Virginia Polytechnic Institute and State University Blacksburg, VA 24061-0436
·
DEVELOPMENT AND BEHAVIOR: OLDER CHILDREN AND ADOLESCENTS
0031-3955/92 $0.00
+ .20
BEHAVIORAL ASSESSMENT OF CHILDREN AND ADOLESCENTS Jack W. Finney, PhD, and Mark D. Weist, PhD
Health encompasses physiologic, psychologic, and social aspects of children's development. From a comprehensive definition of health comes a broad range of goals for pediatric health supervision, including monitoring of children's behavioral development and parents' concerns about their children's behavior problems. 4 A regular schedule of visits for health supervision and periodic visits for acute care provide many opportunities for the assessment of children's behavioral status. Parents and children also may identify concerns about their children's behavior or development during these visits,.' and their concerns may indicate the need for further assessment. By screening, interviewing, and observing children and their parents, primary care clinicians can complete behavioral assessments to determine whether parents and children may benefit from further assessment or therapy for behavioral and development problems. Primary care clinicians have been shown to play an important role in facilitating receipt of mental health services!! as well as to, fail to identify numerous children who may benefit from these services. 12 It therefore is essential that behavioral assessment be better incorporated into primary health care practice. Unlike most mental health professionals, the primary care clinician has opportunities to observe normally developing children throughout childhood and adolescence. Other contacts between the child and physician occur during visits for acute illnesses and injuries. These multiple contacts provide a unique context for behavioral assessment. A series of behavioral and development screenings and assessments can be completed to help assure parents that their children are growing, developing, and behaving within normal (optimal) limits. Alternatively, clinicians may identify potential areas of concern based on a
From the Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, Virginia (JWF); and the Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland (MDW)
PEDIATRIC CLINICS OF NORTH AMERICA VOLUME 39 • NUMBER 3 • JUNE 1992
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parent's worries, fears, and expectations; a parent's apparent capabilities; and a child's present behavioral patterns or characteristics. Ideally, child health supervision should result in the identification of "problems" before they occur or at least before the child's behavior problems are severe or the parent's reactions are intense. Practically, however, early identification of problems and interventions designed to change the course of the early problems will only be a reality when better predictors of future behavior problems are developed. Few studies have identified early predictors, and even fewer have followed children in longitudinal designs of sufficient duration to identify early childhood predictors of later problems of adolescence. A recent exception is a study that found that poor peer relations in early elementary school portend adjustment problems in adolescence, including juvenile delinquency, substance abuse, and poor academic performance. 4 ' Because of limitations inherent in the primary health care system, screening instruments, interviewing, and· parent and child monitoring of behavior are the most feasible assessment techniques for ongoing assessment of the child's behavioral and developmental status. Screening devices of widely varying reliability and validity often are used in primary care, and the inadequacies of some of these have been discussedY 30 Screening, however, can facilitate interviewing. The behavioral interview can be based on screening results, in which the clinician probes for additional information about "red flags" identified by a screening instrument and for other problem areas not covered or perhaps misidentified by a screening device. Information derived from the behavioral interview can indicate important child and parent behaviors that can be monitored by the parent in the home and other natural settings to provide a more objective description of the problem situations. Primary care assessment often requires a reliance on parent and child reports of behavior problems. Observation of parent or child behavior is often time-limited and setting specific (i.e., in the office). Most often, only information derived from interviews is available for the frequency, duration, and intensity of problems, situational characteristics associated with the problem, reactions of parents and others to the child's behavior, and other information relevant for selecting and implementing interventions. More detailed assessments of problem behaviors are often difficult to accomplish in the course of routine primary care, and thus, one weakness of behavioral assessment in primary care settings is that imprecise or incorrect assumptions identified through screening and interviewing may lead to ineffective, or at times, inappropriate treatment recommendations. 49 Research on behavioral and other psychological assessment has shown that a number of problem behaviors that have been identified for intervention often are based on inappropriate assumptions or assessments. 48 . 49 Careful attention to the consistency of information obtained, the use of multiple methods and sources, and the use of reliable and valid assessment practices can assist in avoiding mistaken problem labeling, advice giving, or referral. 38.41
THE FUNCTIONS OF BEHAVIORAL ASSESSMENT IN PRIMARY CARE
Hawkins 26 has identified five functions of behavioral assessment that are relevant for primary care-based assessment (Table 1). Initially, the clinician provides screening to help him or her decide whether a child or family has a problem. If a problem is identified, the clinician must then decide whether further assessment and therapy can be accomplished in primary care visits or
BEHAVIORAL ASSESSMENT OF CHILDREN AND ADOLESCENTS
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Table 1. FIVE FUNCTIONS OF ASSESSMENT FOR CHILDREN AND FAMILIES Screening and General Disposition What are the child's problems? Are the child's problems appropriate for assessment and intervention in primary care? If not, where should the child be referred? If yes, what further assessments are needed? Definition and Extent of the Problem What are the specific behavioral, developmental, and emotional problem(s) and parental concerns? What are the details about the problem (frequency, intensity, situations, consequences, corollary behaviors)? What are possible causes and correlates related to the problem? What do these causes and correlates suggest about possible interventions? Assessment for Designing an Intervention What are specific behavioral objectives for the child and parent? How do parents currently respond to the child's problem behavior? How might their responses be changed? What can the child be taught to enable him or her to avoid problem behaviors? What resources are available to the family for helping with their current situation? Monitoring of Progress How often do the problems occur before and after intervention by the health care provider? Are the changes in behavior clinically (socially) significant and sufficient, or is there a continued need for intervention? Who should provide the additional intervention, the health care provider or a mental health profeSSional? Follow-up Are the problems still present at a future office visit? Have the behavioral changes accomplished earlier lasted? Do the changes continue to be sufficient for making the child, parent, and family successful? Are there new behavior problems and concerns that require additional assessment? Note: The functions of assessment were derived from Hawkins RP: The functions of assessment: Implications for the selection and development of devices for assessing repertoires in clinical, educational. and other settings. J Appl Behav Anal 12:501-516, 1979.
whether referral to a mental health professional would be best. 44 Further details about the specific child, parent, and family problems are needed if the primary care clinician chooses to complete assessment and introduce intervention. In planning for an intervention, the clinician needs to help parents and children establish behavioral objectives, for example, assisting parents in identifying how often a problem may occur before disciplinary actions should be taken. Additional detail about current parenting approaches and ways children can be encouraged to develop new patterns of behavior can be assessed. Once a recommendation is given, the clinician needs to follow the parent and child to determine whether the problem is getting better or worse or staying the same. Determining whether any behavioral improvements are clinically relevant (socially valid]5. 51) or whether new behavioral concerns have occurred informs the clinician about recommending additional assessment or treatment services. At later follow-up health care visits, the clinician can continue to check on the child's and parents' progress to assess the child's development over time, provide any indicated assessment or treatment services, or refer to appropriate mental health professionals.
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A STRUCTURE FOR BEHAVIORAL ASSESSMENT IN PRIMARY CARE
Parents often can complete behavioral questionnaires and screening devices before the encounter with the primary care clinician. Parents obtain information for themselves by completing screening instruments: they learn, for example, that behavioral topics as well as medical and health topics are appropriate for discussion during primary care visits. 16
Behavioral Interview
The behavioral interview can be guided by the parents' responses to screening questionnaires. Remarks about the child's strengths (e.g., plays well independently, completes home responsibilities) can be elicited from parents in conjunction with probes for further details about areas that are identified as problematic. When parents indicate in an interview the problems of most concern, the clinician must obtain further behavioral information to guide the assessment and treatment process. The timing of this additional assessment varies. Some clinicians have some flexibility in schedules that allows for extended discussion during the visit; others need to schedule later appointments to continue the assessment. 25 A number of questions can be used to prompt parents to discuss their children's behavior. Open ended questions are helpful for some parents because they provide a general invitation for parents to mention their concerns. Others may respond best to specific questions about common child behaviors, family living patterns, school performance and activities, and parent-child relationships. Health care clinicians usually have standard questions that they use to generate discussion with parents; if these questions do not encourage interaction with parents, clinicians should continue revising their usual practices to facilitate open communication during visits. 23
Observation During the Visit
Despite the limitations of brief observations in an "unnatural" setting, observation of parent and child interactions can provide information about current parent management techniques. Obvious examples are spankings, frequent scoldings and warnings, parental indifference to the child's behavior in the examination room, or parental inattention to the child's questions. More subtle but perhaps important are facial grimaces, finger shakes as warnings, and noticeable emotional exasperation at what are often common child misbehaviors in a crowded examination room. With older children, parents may be prone to interrupting the children who are asking or answering questions. Frequent interruptions may indicate a parent who is rigid in his or her perceptions of how older children should participate during health care visits. Despite its limitations, careful observation of parent and child behavior during the appointment can assist in determining the presence of behavioral problems or concerns, family problems that may be helped by a therapist or school counselor, and· the extent of management suggestions that may be helpful for the family.
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Monitoring by Parent and Child
An additional source of information can come from the parents and children. The primary care clinician can ask for more details about identified problems by teaching the parent to keep records of child and parent behavior at home. The parent can be instructed to note the frequency, duration, or intensity of specific behaviors, antecedents and consequences of the behaviors, and situational variables. The child also can be asked to record his or her own behaviors that are problematic and parent behaviors that the child thinks may be relevant as well as successful instances of behavior in a usually problematic situation. A structure for recording information should be provided: calendars, notebooks, diaries, or simple data sheets with days and columns can be provided or their purchase recommended (Table 2). Behavioral data, when reviewed with the parent and child at a later appointment, can help to determine the extent of problem situations and can provide the necessary information for implementing an intervention and assessing its effects or can be used for referral for services from mental health professionals. IS In addition to getting more detail about the extent of behavior problems, Table 2. EXAMPLE OF A PARENT MONITORING FORM Child's Name: _ _ _ _ _ _ _ _ _ _ __
BEHAVIOR Makes bed w/out remind
Dressed on time Home on time Hits sister
Sneaks snacks Father nags Mother nags
MON
TUES
WED
Week 01: _ _ __
THUR
FRI
Recorder: _ _ __
SAT
SUN
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self-monitoring can provide information about the family's readiness to work on a clinical problem. A parent's or child's failure to record information regularly may signal the family's lack of structure and routine or the parent's or child's lack of motivation to pursue solutions for the previously identified concerns. Records, whether detailed or sketchy, provide a context for discussing the family's functioning since the last appointment. CONTENT OF ASSESSMENT
As the child ages, the content for behavioral assessment shifts from screening for common developmental milestones to more complex developmental, social, and behavioral achievements and problems. 2• Increasing interaction with peers and adults is required as the child encounters a wider range of social situations such as school, recreational activities, and shopping. A number of assessment and screening inventories have been developed to cover a wide range of child behavior (Table 3). Uses for these and other inventories have been discussed at length. 19. 34, 36. 37 Social Relationships
When the primary care clinician incorporates behavioral assessment into health care, discussion of the child's social relationships and developmental levels becomes a critical part of the assessment. Parent-child interactions form the basic socialization process for infants and young children. All physical needs are mediated by the parent, and most social needs are initially mediated by the parent. Thus, it is important for clinicians to assess the parent's knowledge of and responsiveness to an infant's signs of physical and emotional needs lO and to assess continuously the development of the child's social communication abilities. Standardized observational systems have been developed to assess, for Table 3. ASSESSMENT AND SCREENING INVENTORIES FOR PRIMARY CARE SETTINGS Developmental Screening Brazelton Neonatal Assessment Scale? Denver Developmental Screening Test (Revised)21 Denver Prescreening Developmental Questionnaire2' Kansas Infant Development Scale'? Assessment of Home Situations Relevant to Behavior and Development HOME Inventory Scale" Home Screening Questionnaire (HSQ)2° Behavior Problems Brief Symptom Checklist28 40 Eyberg Child Behavior Inventory14 Child Behavior Checklist ' - 3 Connors Parent Symptom Rating Scale 24 SchoolPerlormance Aggregate Neurobehavioral Student Health and Education Review (ANSER) System 31 Pediatric Examination of Educational Readiness (PEER)32,35 Pediatric Early Elementary Examination (PEEX)34 Pediatric Examination of Educational Readiness at Middle Childhood (PEERAMID)33
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example, eye contact, method of holding the infant, and other physical interaction characteristics of the parent and child,46 but extensive observational data are unwieldy to obtain in a primary care setting. Therefore, the clinician must obtain as much information about the parents' care-giving, responsiveness to the child, and other features of parenting skills through interviews or questionnaires. For older children, social relationships can be assessed by a standardized behavioral questionnaire (e.g., the Child Behavior ChecklisP). School information on the child's performance and participation in activities can provide additional information about the child's development in this area. 30 Developmental Considerations
To be effective, child behavioral assessment and the advice provided based on the assessment must be consonant with the developmental level of the child. s. 42 Many developmental skills occur in a relatively orderly fashion: many children creep, crawl, cruise, and then finally walk, each advancement in skill corresponding to the physical and cognitive development of the child. Training before the child has developed the requisite physical development often is unsuccessful or at least unpleasant for the child, the parent, or both. For example, children are unlikely to attain independence in tOileting until the bladder, musculoskeletal system, and nervous system have developed sufficiently for bladder control to be physically and cognitively possible. Easily observed behaviors serve as indicators of biologiC and psychological maturation. For example, numerous toilet training readiness criteria (e.g., bladder control, finger and hand coordination, responsiveness to parent instructions) have been identified. 5 The success of this approach supports the assumption that the readiness behaviors are directly related to the important physical and cognitive developmental characteristics needed for achieving independent toileting. The primary care clinician can assess through a combination of interview and observation the child's performance on these criteria and counsel parents according to the child's attainments about the timing and techniques of a range of skills once similar developmental readiness skills have been elaborated. Older children and adolescents also must be monitored for development of independence and responsibility. Discussion of the parent's perceptions of the older child's or adolescent's need for parental or other adult supervision could aid in helping parents to decide, for example, when it would be appropriate to leave a child at home alone, when to expect a child to perform a number of regular home chores, and when to allow a child to date or attend an unsupervised party. Assessment of adolescent development has received limited attention; however, key areas for assessment include perceived academic and social competence, performance in school, success with peer relations (e.g., dating), planning for college or a vocation, and pressures to use alcohol or other drugs. The health care clinician can begin with these issues in his or her assessment of the adolescent when behavioral issues are addressed. Each clinician must develop comfort and competence in assessing the difficult dilemmas faced by adolescents and their parents and in advice that is offered to these families. Assessment of Reactions to Children's Illness Behavior
Primary care clinicians are in a unique position to monitor the interaction of illnesses with social and environmental events that can result in new or
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sustained illness behavior patterns in children. The child who has repeated ear infections with related hearing loss often can appear to be "deaf" to parent instructions long after fluid is no longer present in the ear canal. Similarly, the child who has flu-like symptoms may persist in "sick" behavior long after fever, chills, vomiting, diarrhea, and other acute symptoms have disappeared. Is the child still sick? Perhaps, but often changes in parental expectations, attention to sick behavior, and avoidance of undesired activities (e.g., school attendance, home chores) can result in prolonged illness behavior.47,0 The primary care clinician must assess the likely changes in parental management that may account for prolonged sick behavior and suggest, after complete medical and behavioral assessment, possible changes in parent management style, behavior, and attitudes that foster renewed health and activities in the child." THE VALUE OF BEHAVIORAL ASSESSMENT IN PRIMARY CARE
The incorporation of behavioral assessment in primary care results in significant advances in addressing children's behavioral and developmental problems. Primary care clinicians can obtain more detailed information about parent concerns, child behavior, and environmental and social interactions using screening questionnaires, conducting a behavioral interview, and having parents and children monitor their behavior in home and school settings. Such assessment data provide the basis for determining the severity of problems, the types of interventions likely to be effective in resolution of the behavior problems, and the need for referral for mental health services. Primary care clinicians can be considered a "first line of defense" for identification and remediation of common behavioral and developmental problems of childhood. As the gatekeepers of mental health care,l1 primary care clinicians need to incorporate behavioral assessment. Through repeated monitoring of children, the clinician can determine areas for which parents and children will benefit from more intensive assessment and treatment in primary care. Both behavioral assessment and treatment services require changes in primary health care, including training in the theory and practice of psychological assessment and treatment, restructuring of pediatric practice to include longer and repeated appointments for these services, and appropriate fees for these new levels of services. These changes provide an improved health care system that is responsive to all aspects of children's health.
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Address reprint requests to Jack W. Finney, PhD Department of Psychology Virginia Polytechnic Institute and State University Blacksburg, VA 24061-0436
