The
Importance of Parents’ Concerns About Their Child’s Behavior
Frances P. Glascoe, Ph.D.*, William E. MacLean, Ph.D.**, Wendy L. Stone, Ph.D.*
Parents often complain about children’s behavior. Pediatricians may be unsure whether to ignore these complaints, counsel parents in-office or refer them to mental health services. This study shows a close relationship between parents’ concerns and measurably significant behavior problems. Methods are provided for responding to parents’ concerns. These should be useful to pediatricians who are often criticized for failing to detect and refer children with mental health problems including behavior disturbances.
Most parents waiting in pediatric offices have a variety concerns about their children. Concerns are the most common and are raised by 24% to 31%.1,2 These complaints may be vague or focus on behaviors often considered normal for young children. When confronted with a parental concern, pediatricians of non-medical about behavior
are
likely
to
search for evidence of problems by observing
children’s behavior. However, problematic behavior may be demonstrated only inconsistently and is often amenable to control by unfamiliar persons.3-5 Even children with significant conduct or other mental health problems may behave appropriately during brief office visits which may explain why they are often under-detected by physicians.3,6-1O All of this leaves pediatricians unsure whether
*Child Development Center, Department of Pediatrics, **Departof Psychology, Vanderbilt University, Nashville, Tennessee. Correspondence to: Dr. Frances P. Glascoe, Child Development Center, Vanderbilt University Medical Center South, 2100 Pierce Avenue, Nashville, TN 37232 ment
downplay parents’ complaints, counsel parents inoffice, administer behavioral screening tests orrefer directly to
for behavioral intervention or other mental health services. The present study focuses on the meaning behind parents’ concerns in order to help pediatricians decide how to
respond to complaints about children’s behavior. Method
Subject and Sites Subjects were 95 parent-child dyads seeking pediatric in: (a) one of two urban teaching hospitals in Nashville, Tennessee (16%); or (b) one of three private pediatric practices, two in the city limits and one in an outlying county (84%). Parents of children seeking health services care
who were between 24 and 78 months of age and who were not acutely ill were asked to participate. Four declined. Most of the participating parents were mother (82%), married (77%), had a twelfth grade or greater education (85%) and were from urban/suburban areas (62%). The children were typically Caucasian (85%), male (56%) and first bom (60%). They averaged 48 months of age
8 Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on June 19, 2015
(range=24-77 months, standard deviation (sd)=13.40), usually had siblings (78%) and participated in day care or school programs (76%). Procedures One of three doctoral candidates in psychology asked each parent, &dquo;Please tell me any concerns you have about your child’s learning and development.&dquo; From previous research with this question, parents’ responses can be reliably categorized as: no concerns, concerns about behavior control, gross and fine motor, receptive and expressive language, articulation, personal-adaptive, socialaffective, school skills, medical/sensory status, and/or
global development. 11,12 domain
A second
question probed each
that parents did not omit any concerns, i.e., &dquo;Do you have any concerns about the way he/she talks, listens, behaves, takes care of himself...,&dquo; etc. Only data on the parents’ concerns about children’s behavior were used in the present study. Since parents are known to provide accurate descriptions of current behavior and since parent report measures are the most frequently employed assessment technique in evaluating young children,&dquo; after parents stated their concerns, they were asked to complete the Eyberg Child Behavior Inventory (ECBI).14,15 The ECBI is a list of 36 typical problem behaviors reported by parents of conduct problem children-defined as patients receiving services at a behavioral pediatric clinic. Standardized on 512 generally low income children between 2 and 12 years of age, normally behaving children average four to six problem behaviors while conduct problem children average 19 to 21 problem behaviors. 14- 11 The presence of 16 or more problem behaviors (>2 sds above mean for normally behaving children) suggests the presence of significant conduct problems&dquo;,&dquo; and a need for referral. Data were coded and entered into a VAX8800 computer system. Analyses included chi-square and t-tests from the SPSSX statistical program. to ensure
(had 16
or more behavior problems). Seventy-five chil(79%) passed. Table 1 shows the percentage of parents encountering each type of behavior problem. Children’s pass/fail performance on the ECBI was then compared with the presence or absence of parents’ concerns about behavior: (a) 14 of the 20 children who failed the ECBI had parents with concerns, such that parents’ concerns were 70% sensitive to conduct problems; (b) 55 of the 75 children who passed the ECBI had parents without concerns. Thus, the absence of parental concerns was 73% specific in identifying children with normal behavior as such; (c) of the 34 parents with concerns about behavior, 14 had children with significant behavior problems, such that the positive predictive value of parents’ concerns was 41 %; and (d) of the 61 parents without concerns, 55 had
dren
children without serious behavior problems, for a negative predictive value of 90%. Table 2 shows the comparison of parents’ concerns to ECBI scores. TABLE 1. Behavior Problems In Order of Encountered by 95 Parents
Frequency
Results of the 95 parents, 8%, spontaneously raised about their child’s behavior (e.g., &dquo;he’s stubborn...overly active...aggravating...throws fits... spoiled..won’t listen...can’t pay attention...aggressive,&dquo; etc.) Twenty-six additional parents (27%) acknowledged concerns about behavior when asked. A total of 34 of the 95 parents (36%) had concerns about their child’s behavior. The remaining 61 parents (64%) had no or other
Eight (8)
concerns
concerns.
Twenty (20) of the 95
children
(21 %) failed the ECBI
9 Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on June 19, 2015
TABLE 2. Predictive Value of Parents’ Concerns About Their Child’s Conduct
havior
problems, the false-negative group (N=6) was compared to the group of children who also failed the ECBI but whose parents were concerned (N=14). However, there were no significant differences between groups on any demographic variable or type of behavior problem. Discussion
Demographic and Other Influences on the Accuracy of Parents’ Concerns In an effort to discern why some parents had concerns even though their children had normal behavior, the 20 parents with unvalidated concerns (false-positives) were compared to the 14 parents with validated concerns. Other than variation in ECBI performance (an average of 20 different behavior problems in the validated group and an average of 10 in the unvalidated group), there were no demographic or other markers distinguishing the two groups, i.e., no differences on the basis of parents’ level of education, area of residence, marital status, gender, number of offspring, perception that children had significant versus nonsignificant medical histories, research site, or children’s gender, birth order, participation in day care or school programs, race or age. Nevertheless, the unvalidated group (N=20) had significantly more behavior problems (mean=10, sd=3.28) than did children who also passed but whose parents were not concerned (N=55), (mean=6.6, Item differences between sd=3.9) [t(73)=4.01, p
Importance of Parents’ Concerns About Their Child’s Behavior
Frances P. Glascoe, Ph.D.*, William E. MacLean, Ph.D.**, Wendy L. Stone, Ph.D.*
Parents often complain about children’s behavior. Pediatricians may be unsure whether to ignore these complaints, counsel parents in-office or refer them to mental health services. This study shows a close relationship between parents’ concerns and measurably significant behavior problems. Methods are provided for responding to parents’ concerns. These should be useful to pediatricians who are often criticized for failing to detect and refer children with mental health problems including behavior disturbances.
Most parents waiting in pediatric offices have a variety concerns about their children. Concerns are the most common and are raised by 24% to 31%.1,2 These complaints may be vague or focus on behaviors often considered normal for young children. When confronted with a parental concern, pediatricians of non-medical about behavior
are
likely
to
search for evidence of problems by observing
children’s behavior. However, problematic behavior may be demonstrated only inconsistently and is often amenable to control by unfamiliar persons.3-5 Even children with significant conduct or other mental health problems may behave appropriately during brief office visits which may explain why they are often under-detected by physicians.3,6-1O All of this leaves pediatricians unsure whether
*Child Development Center, Department of Pediatrics, **Departof Psychology, Vanderbilt University, Nashville, Tennessee. Correspondence to: Dr. Frances P. Glascoe, Child Development Center, Vanderbilt University Medical Center South, 2100 Pierce Avenue, Nashville, TN 37232 ment
downplay parents’ complaints, counsel parents inoffice, administer behavioral screening tests orrefer directly to
for behavioral intervention or other mental health services. The present study focuses on the meaning behind parents’ concerns in order to help pediatricians decide how to
respond to complaints about children’s behavior. Method
Subject and Sites Subjects were 95 parent-child dyads seeking pediatric in: (a) one of two urban teaching hospitals in Nashville, Tennessee (16%); or (b) one of three private pediatric practices, two in the city limits and one in an outlying county (84%). Parents of children seeking health services care
who were between 24 and 78 months of age and who were not acutely ill were asked to participate. Four declined. Most of the participating parents were mother (82%), married (77%), had a twelfth grade or greater education (85%) and were from urban/suburban areas (62%). The children were typically Caucasian (85%), male (56%) and first bom (60%). They averaged 48 months of age
8 Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on June 19, 2015
(range=24-77 months, standard deviation (sd)=13.40), usually had siblings (78%) and participated in day care or school programs (76%). Procedures One of three doctoral candidates in psychology asked each parent, &dquo;Please tell me any concerns you have about your child’s learning and development.&dquo; From previous research with this question, parents’ responses can be reliably categorized as: no concerns, concerns about behavior control, gross and fine motor, receptive and expressive language, articulation, personal-adaptive, socialaffective, school skills, medical/sensory status, and/or
global development. 11,12 domain
A second
question probed each
that parents did not omit any concerns, i.e., &dquo;Do you have any concerns about the way he/she talks, listens, behaves, takes care of himself...,&dquo; etc. Only data on the parents’ concerns about children’s behavior were used in the present study. Since parents are known to provide accurate descriptions of current behavior and since parent report measures are the most frequently employed assessment technique in evaluating young children,&dquo; after parents stated their concerns, they were asked to complete the Eyberg Child Behavior Inventory (ECBI).14,15 The ECBI is a list of 36 typical problem behaviors reported by parents of conduct problem children-defined as patients receiving services at a behavioral pediatric clinic. Standardized on 512 generally low income children between 2 and 12 years of age, normally behaving children average four to six problem behaviors while conduct problem children average 19 to 21 problem behaviors. 14- 11 The presence of 16 or more problem behaviors (>2 sds above mean for normally behaving children) suggests the presence of significant conduct problems&dquo;,&dquo; and a need for referral. Data were coded and entered into a VAX8800 computer system. Analyses included chi-square and t-tests from the SPSSX statistical program. to ensure
(had 16
or more behavior problems). Seventy-five chil(79%) passed. Table 1 shows the percentage of parents encountering each type of behavior problem. Children’s pass/fail performance on the ECBI was then compared with the presence or absence of parents’ concerns about behavior: (a) 14 of the 20 children who failed the ECBI had parents with concerns, such that parents’ concerns were 70% sensitive to conduct problems; (b) 55 of the 75 children who passed the ECBI had parents without concerns. Thus, the absence of parental concerns was 73% specific in identifying children with normal behavior as such; (c) of the 34 parents with concerns about behavior, 14 had children with significant behavior problems, such that the positive predictive value of parents’ concerns was 41 %; and (d) of the 61 parents without concerns, 55 had
dren
children without serious behavior problems, for a negative predictive value of 90%. Table 2 shows the comparison of parents’ concerns to ECBI scores. TABLE 1. Behavior Problems In Order of Encountered by 95 Parents
Frequency
Results of the 95 parents, 8%, spontaneously raised about their child’s behavior (e.g., &dquo;he’s stubborn...overly active...aggravating...throws fits... spoiled..won’t listen...can’t pay attention...aggressive,&dquo; etc.) Twenty-six additional parents (27%) acknowledged concerns about behavior when asked. A total of 34 of the 95 parents (36%) had concerns about their child’s behavior. The remaining 61 parents (64%) had no or other
Eight (8)
concerns
concerns.
Twenty (20) of the 95
children
(21 %) failed the ECBI
9 Downloaded from cpj.sagepub.com at UNIV OF MICHIGAN on June 19, 2015
TABLE 2. Predictive Value of Parents’ Concerns About Their Child’s Conduct
havior
problems, the false-negative group (N=6) was compared to the group of children who also failed the ECBI but whose parents were concerned (N=14). However, there were no significant differences between groups on any demographic variable or type of behavior problem. Discussion
Demographic and Other Influences on the Accuracy of Parents’ Concerns In an effort to discern why some parents had concerns even though their children had normal behavior, the 20 parents with unvalidated concerns (false-positives) were compared to the 14 parents with validated concerns. Other than variation in ECBI performance (an average of 20 different behavior problems in the validated group and an average of 10 in the unvalidated group), there were no demographic or other markers distinguishing the two groups, i.e., no differences on the basis of parents’ level of education, area of residence, marital status, gender, number of offspring, perception that children had significant versus nonsignificant medical histories, research site, or children’s gender, birth order, participation in day care or school programs, race or age. Nevertheless, the unvalidated group (N=20) had significantly more behavior problems (mean=10, sd=3.28) than did children who also passed but whose parents were not concerned (N=55), (mean=6.6, Item differences between sd=3.9) [t(73)=4.01, p
