- Email: [email protected]
Use of a behavior checklist on a pediatric inpatient unit
15 6
Schneider and Rice
10. Jensen R, and Wert A: Conversion hysteria in children, J Lancet 65:172, 1945. 11. LiskeE, and Forster F: Pseudoseizures: A problem in the diagnosis and management of epileptic patients, Neurology 14:41, 1964. 12. Kiloh L, McComas A, and Osselton J: Clinical electroencephalography, London, 1972. Butterworth & Co., Ltd., p 192. 13. WilliamsD, Spiegel H, and Mostofsky D: Neurogenic and
The Journal of Pediatrics January 1979
hysterical seizures in children and adolescents: Differential diagnostic and therapeutic considerations, Am J Psychiatry 135:82, 1978. 14. DeJongR: The neurological examination, ed 3, New York, 1969 Harper & Row, Publishers, pp 989-1015. 15. Weintraub M: Hysteria: A clinical guide to diagnosis, C1BA Clinical Symposia 29, 1977. 16. Holt LE: Diseases of infancy and childhood, New York, 1898, Appleton, p 688.
Brief clinical and laboratory observation Use o f a behavior checkl&t on a pediatric inpatient unit Michael Jellinek, M.D.,* Nina Evans, M.D., and Rona B. Knight, Ph.D., Bronx, N. Y.
EMOTIONAL OR BEHAVIORAL DISORDERS are often hard to define in objective terms and, until recently, have not been given educational priority in some pediatric curricula. On an inpatient service, behavioral and emotional issues often give way to "completing the work-up" and providing acute care. Some children do get referred to a child psychiatrist for developmental evaluation or on the basis of clear indication such as rape, suicide attempt, or bizarre behavior. However, most children over age 3 or 4 years go through the admissions process with little attention to emotional or behavioral issues. In this preliminary study we attempted to develop a set of behavioral questions in a checklist format for 7- to 1 l-year-old inpatients. We hoped that the checklist would facilitate communication between mother and pediatrician, train pediatric houseofficers by providing a short list of questions that fit into the medical review of systems model, and generate a score that would suggest the need for psychiatric consultation. The checklist we studied is a major modification of the Washington Symptom Checklist used by Weinberger and Gregory. l In their study of patients in a child psychiatric outpatient clinic~ they found that the WSCL was useful in From the Department of Pediatrics, Montefiore Hospital and Medical Center. *Reprint address: 15 Rose Garden Circle, Boston, MA 02135
eliciting data from the mother during the clinic intake interview. We modified the WSCL by decreasing the number of questions from 67 to 27, and eliminated open-ended questions in an effort to shorten the time required for administration. Further, we narrowed and changed questions on the basis of our own "review of systems" aproach. For children between the ages of 7 and 11 we "review" five major areas: mood, play, school, friends, and family relations. Our checklist reflects an attempt at integrating clinical concepts and behavioral questions with special concern for ease of administration and brevity. Abbreviations used WSCL: Washington Symptom Checklist SES: socioeconomicstatus A major question in this type of study is whether the mother is an accurate reporter of her child's behavior. Although the mother knows the most about the child, her information is open to major distortion and subjectivity. Gtidewell et al 2 found that mothers were reliable in describing the number, duration, and severity of symptoms. A more recent study :' used a modified WSCL retrospectively to evaluate 30 inpatients who were referred to a child psychiatrist and, as controls, used 60 inpatients who were not referred. The results indicated the potential value of a behavioral checklist; however, virtual-
0022-3476/79/100156 +03500.30/0 9 1979 The C. V. Mosby Co.
Volume 94 Number 1
ly half of the referred group had lower than expected scores, leading the authors to warn that the denial defense may falsely lower some checklist scores. The current study is a pilot effort to investigate our behavioral checklist for use as a screening method on a busy pediatric inpatient service. METHODS Subjects and setting. A total of 21 children, 16 boys and five girls, were studied between the ages of 7 and 11 years. All were admitted to the Montefiore Hospital Pediatric Service on a scheduled basis for elective surgery, excluding major abdominal or thoracic surgery. Context of study. The behavioral checklist and psychiatric interview were done as part of a larger study 4" ' that included more extensive demographic analysis, psychologic testing, observation of recovery rates, additional interviews, ward observations, and collection of 24-hour urine specimens to measure cortisol levels. Written consent was obtained from parents and oral consent from the children. Demographic data. Subject's age, sex, history of previous hospitalization, race, parental education, and parental employment were reviewed. Socioeconomic status was defined by the Hollingshead two factor method." Behavioral checklist. The checklist questions (Table I) were asked of the child's mother during the admission history by the pediatric houseofficer. The scoring was based on a point system, zero for never, one point for sometimes, and two points for often. (This scoring sequence was reversed, because of the wording, in questions 20 and 26.) The administration of the checklist took approximately five minutes. Child psychiatric interview. Each child was interviewed twice, 24 hours pre- and postsurgery, by a child psychiatrist. Clinical assessments did not include parental interview and were done without knowledge of the checklist results. The interview usually opened with a brief conversation about the child's friends and special likes, proceeding to discussion of school and family, and then of the impending operation. The interview was primarily focused on the here-and-now except for a review of prior hospitalization experiences. Three areas dominated the clinical scoring: the psychiatrist's perceptions of the child's relatedness, the child's capacity to utilize the interview as an aid to mastery of the stresses occasioned by hospitalization, and the ability to engage in play. The psychiatrist rated the child on a five point scale: 1. Child is well adjusted, coping well with hospitalization. 2. Child is adequately adjusted, mild stress response accompanying adequate coping with hospitalization. 3. Child with
Brief clinical and laboratory observations
15 7
Table I. Behavioral checklist 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.
Prefers to play alone Gets hurt in major accidents Does he/she ever play with fire Has difficulties with teachers Gets poor grades in school Is absent from school Becomes angry easily Daydreams Feels unhappy Acts younger than other children his/her age Does not listen to parents Does not Jell the truth Unsure of himself/herself Has trouble sleeping Seems afraid of someone or something Is nervous and jumpy Has a nervous habit Does not show feelings Fights with other children Is understanding of other people's feelings Refuses to share Shows jealousy Takes things that are not his/hers Blames others for his/her troubles Prefers to play with children not his/her age Gets along well with grown-ups Teases others
Table II
Psychiatric interview rating*
11213
415
8 9 3 0 Number of subjects (total 1 n = 21) 1 2 3 4 Psychiatric interview rating 2.7 Psychiatric rating mean Behavioral checklist score 4 7-17 10-22 27-38 -Range 4 12 17 31 -Mean 4 13 18 29 -Median 16.7 Mean checklist score Psychiatric interview/checklist correlation: r = 0.85, P < 0.001
*Per interviewrating category. moderate difficulty coping, possible candidate for further psychiatric evaluation. 4. Child with major difficulty coping, in definite need of psychiatric crisis support and further evaluation. 5. Child acutely psychotic or suicidal. RESULTS Demographic data. The only demographic finding of note is that all but two of the children were in SES Class
158
Brief clinical and laboratory observations
IV and V (Hollingshead and Redlich's two lowest class designations). There were no trends in age, sex, race, or diagnosis and the results of psychiatric interview or checklist scores. Checklist: Psychiatric interview correlation. There was a statistically significant correlation between the checklist score and the rating derived from the psychiatric interview (r = 0.85, P < 0.001 by Pearson Product correlation). See Table lI for complete results. The checklist did not always differentiate patients who clinically were rated two to three. Two patients were rated by interview one category higher and one patient was rated one category lower than predicted by the checklist score. The checklist (score 22) and clinical interview (rating of 4) selected the same three of 21 children (14%) who were definitely felt to require psychiatric intervention. DISCUSSION The results of this preliminary study suggest that a brief behavioral checklist administered by a pediatrician to a child's mother can discriminate a subgroup of children who require psychiatric evaluation and support. The checklist was in agreement with clinical psychiatric interview, in selecting prospectively three of 21 children (14%) who needed psychiatric intervention and, with a history of recent clinic visits, had never been referred previously. The checklist results, on the basis of this small sample, indicate that a score above 22 suggests the need for psychiatric evaluation and that a score of 15 to 22 suggests the need for closer observation, more complete history, and, with adequate resources, possible psychiatric referral.
The Journal ~?f Pediatrics January 1979 On a theoretical level the checklist results suggest that children who would benefit from psychiatric referral often have diffuse, not isolated areas of dysfunction. Mothers who scored their children in the high range were expressing doubts or serious concerns in the areas of peer relationships, school performance, family life, mood, and quality of play. Clearly this research is of a preliminary nature and requires careful elaboration to determine whether the checklist be useful in large outpatient populations, whether the stress of hospitalization significantly altered the clinical interview, etc. The checklist did encourage pediatric houseofficers to ask questions evaluating behavioral and emotional areas in children that are beyond the age where developmental landmarks are very useful.
REFERENCES l. Weinberger RC, and Gregory RJ: A behavior checklist for use in child psychiatry clinics. Am Acad Child Psychiatry 7:677, 1968. 2. Glidewell J, Mensh I, and Gilden M: Behavior symptoms in children and the degree of sickness, Am J Psychiatry 114:47, 1957. 3, Awad GA, and Pozanski EO: Psychiatric consultations in a pediatric hospital Am J Psychiatry 132:915, 1975. 4. Knight RB: Coping mechanisms used by children hospitalized for elective surgery, Dissertation, Yeshiva University, June, 1977. 5. Knight RB, Atkins A, Eagle C, Evans N, Finkelstein JW, Fukushima D, Katz J, and Weiner H: Psychological stress, ego defense, and cortisol production in children hospitalized for elective surgery, Psychosom Med (in press). 6. Hollingshead AB: Two factor index of social position, copyrighted by author 195Z
Schneider and Rice
10. Jensen R, and Wert A: Conversion hysteria in children, J Lancet 65:172, 1945. 11. LiskeE, and Forster F: Pseudoseizures: A problem in the diagnosis and management of epileptic patients, Neurology 14:41, 1964. 12. Kiloh L, McComas A, and Osselton J: Clinical electroencephalography, London, 1972. Butterworth & Co., Ltd., p 192. 13. WilliamsD, Spiegel H, and Mostofsky D: Neurogenic and
The Journal of Pediatrics January 1979
hysterical seizures in children and adolescents: Differential diagnostic and therapeutic considerations, Am J Psychiatry 135:82, 1978. 14. DeJongR: The neurological examination, ed 3, New York, 1969 Harper & Row, Publishers, pp 989-1015. 15. Weintraub M: Hysteria: A clinical guide to diagnosis, C1BA Clinical Symposia 29, 1977. 16. Holt LE: Diseases of infancy and childhood, New York, 1898, Appleton, p 688.
Brief clinical and laboratory observation Use o f a behavior checkl&t on a pediatric inpatient unit Michael Jellinek, M.D.,* Nina Evans, M.D., and Rona B. Knight, Ph.D., Bronx, N. Y.
EMOTIONAL OR BEHAVIORAL DISORDERS are often hard to define in objective terms and, until recently, have not been given educational priority in some pediatric curricula. On an inpatient service, behavioral and emotional issues often give way to "completing the work-up" and providing acute care. Some children do get referred to a child psychiatrist for developmental evaluation or on the basis of clear indication such as rape, suicide attempt, or bizarre behavior. However, most children over age 3 or 4 years go through the admissions process with little attention to emotional or behavioral issues. In this preliminary study we attempted to develop a set of behavioral questions in a checklist format for 7- to 1 l-year-old inpatients. We hoped that the checklist would facilitate communication between mother and pediatrician, train pediatric houseofficers by providing a short list of questions that fit into the medical review of systems model, and generate a score that would suggest the need for psychiatric consultation. The checklist we studied is a major modification of the Washington Symptom Checklist used by Weinberger and Gregory. l In their study of patients in a child psychiatric outpatient clinic~ they found that the WSCL was useful in From the Department of Pediatrics, Montefiore Hospital and Medical Center. *Reprint address: 15 Rose Garden Circle, Boston, MA 02135
eliciting data from the mother during the clinic intake interview. We modified the WSCL by decreasing the number of questions from 67 to 27, and eliminated open-ended questions in an effort to shorten the time required for administration. Further, we narrowed and changed questions on the basis of our own "review of systems" aproach. For children between the ages of 7 and 11 we "review" five major areas: mood, play, school, friends, and family relations. Our checklist reflects an attempt at integrating clinical concepts and behavioral questions with special concern for ease of administration and brevity. Abbreviations used WSCL: Washington Symptom Checklist SES: socioeconomicstatus A major question in this type of study is whether the mother is an accurate reporter of her child's behavior. Although the mother knows the most about the child, her information is open to major distortion and subjectivity. Gtidewell et al 2 found that mothers were reliable in describing the number, duration, and severity of symptoms. A more recent study :' used a modified WSCL retrospectively to evaluate 30 inpatients who were referred to a child psychiatrist and, as controls, used 60 inpatients who were not referred. The results indicated the potential value of a behavioral checklist; however, virtual-
0022-3476/79/100156 +03500.30/0 9 1979 The C. V. Mosby Co.
Volume 94 Number 1
ly half of the referred group had lower than expected scores, leading the authors to warn that the denial defense may falsely lower some checklist scores. The current study is a pilot effort to investigate our behavioral checklist for use as a screening method on a busy pediatric inpatient service. METHODS Subjects and setting. A total of 21 children, 16 boys and five girls, were studied between the ages of 7 and 11 years. All were admitted to the Montefiore Hospital Pediatric Service on a scheduled basis for elective surgery, excluding major abdominal or thoracic surgery. Context of study. The behavioral checklist and psychiatric interview were done as part of a larger study 4" ' that included more extensive demographic analysis, psychologic testing, observation of recovery rates, additional interviews, ward observations, and collection of 24-hour urine specimens to measure cortisol levels. Written consent was obtained from parents and oral consent from the children. Demographic data. Subject's age, sex, history of previous hospitalization, race, parental education, and parental employment were reviewed. Socioeconomic status was defined by the Hollingshead two factor method." Behavioral checklist. The checklist questions (Table I) were asked of the child's mother during the admission history by the pediatric houseofficer. The scoring was based on a point system, zero for never, one point for sometimes, and two points for often. (This scoring sequence was reversed, because of the wording, in questions 20 and 26.) The administration of the checklist took approximately five minutes. Child psychiatric interview. Each child was interviewed twice, 24 hours pre- and postsurgery, by a child psychiatrist. Clinical assessments did not include parental interview and were done without knowledge of the checklist results. The interview usually opened with a brief conversation about the child's friends and special likes, proceeding to discussion of school and family, and then of the impending operation. The interview was primarily focused on the here-and-now except for a review of prior hospitalization experiences. Three areas dominated the clinical scoring: the psychiatrist's perceptions of the child's relatedness, the child's capacity to utilize the interview as an aid to mastery of the stresses occasioned by hospitalization, and the ability to engage in play. The psychiatrist rated the child on a five point scale: 1. Child is well adjusted, coping well with hospitalization. 2. Child is adequately adjusted, mild stress response accompanying adequate coping with hospitalization. 3. Child with
Brief clinical and laboratory observations
15 7
Table I. Behavioral checklist 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.
Prefers to play alone Gets hurt in major accidents Does he/she ever play with fire Has difficulties with teachers Gets poor grades in school Is absent from school Becomes angry easily Daydreams Feels unhappy Acts younger than other children his/her age Does not listen to parents Does not Jell the truth Unsure of himself/herself Has trouble sleeping Seems afraid of someone or something Is nervous and jumpy Has a nervous habit Does not show feelings Fights with other children Is understanding of other people's feelings Refuses to share Shows jealousy Takes things that are not his/hers Blames others for his/her troubles Prefers to play with children not his/her age Gets along well with grown-ups Teases others
Table II
Psychiatric interview rating*
11213
415
8 9 3 0 Number of subjects (total 1 n = 21) 1 2 3 4 Psychiatric interview rating 2.7 Psychiatric rating mean Behavioral checklist score 4 7-17 10-22 27-38 -Range 4 12 17 31 -Mean 4 13 18 29 -Median 16.7 Mean checklist score Psychiatric interview/checklist correlation: r = 0.85, P < 0.001
*Per interviewrating category. moderate difficulty coping, possible candidate for further psychiatric evaluation. 4. Child with major difficulty coping, in definite need of psychiatric crisis support and further evaluation. 5. Child acutely psychotic or suicidal. RESULTS Demographic data. The only demographic finding of note is that all but two of the children were in SES Class
158
Brief clinical and laboratory observations
IV and V (Hollingshead and Redlich's two lowest class designations). There were no trends in age, sex, race, or diagnosis and the results of psychiatric interview or checklist scores. Checklist: Psychiatric interview correlation. There was a statistically significant correlation between the checklist score and the rating derived from the psychiatric interview (r = 0.85, P < 0.001 by Pearson Product correlation). See Table lI for complete results. The checklist did not always differentiate patients who clinically were rated two to three. Two patients were rated by interview one category higher and one patient was rated one category lower than predicted by the checklist score. The checklist (score 22) and clinical interview (rating of 4) selected the same three of 21 children (14%) who were definitely felt to require psychiatric intervention. DISCUSSION The results of this preliminary study suggest that a brief behavioral checklist administered by a pediatrician to a child's mother can discriminate a subgroup of children who require psychiatric evaluation and support. The checklist was in agreement with clinical psychiatric interview, in selecting prospectively three of 21 children (14%) who needed psychiatric intervention and, with a history of recent clinic visits, had never been referred previously. The checklist results, on the basis of this small sample, indicate that a score above 22 suggests the need for psychiatric evaluation and that a score of 15 to 22 suggests the need for closer observation, more complete history, and, with adequate resources, possible psychiatric referral.
The Journal ~?f Pediatrics January 1979 On a theoretical level the checklist results suggest that children who would benefit from psychiatric referral often have diffuse, not isolated areas of dysfunction. Mothers who scored their children in the high range were expressing doubts or serious concerns in the areas of peer relationships, school performance, family life, mood, and quality of play. Clearly this research is of a preliminary nature and requires careful elaboration to determine whether the checklist be useful in large outpatient populations, whether the stress of hospitalization significantly altered the clinical interview, etc. The checklist did encourage pediatric houseofficers to ask questions evaluating behavioral and emotional areas in children that are beyond the age where developmental landmarks are very useful.
REFERENCES l. Weinberger RC, and Gregory RJ: A behavior checklist for use in child psychiatry clinics. Am Acad Child Psychiatry 7:677, 1968. 2. Glidewell J, Mensh I, and Gilden M: Behavior symptoms in children and the degree of sickness, Am J Psychiatry 114:47, 1957. 3, Awad GA, and Pozanski EO: Psychiatric consultations in a pediatric hospital Am J Psychiatry 132:915, 1975. 4. Knight RB: Coping mechanisms used by children hospitalized for elective surgery, Dissertation, Yeshiva University, June, 1977. 5. Knight RB, Atkins A, Eagle C, Evans N, Finkelstein JW, Fukushima D, Katz J, and Weiner H: Psychological stress, ego defense, and cortisol production in children hospitalized for elective surgery, Psychosom Med (in press). 6. Hollingshead AB: Two factor index of social position, copyrighted by author 195Z