Computerized adaptive testing to screen children for emotional and behavioral problems by preventive child healthcare.

BACKGROUND: Questionnaires to detect emotional and behavioral problems (EBP) in Preventive Child Healthcare (PCH) should be short which potentially affects validity and reliability. Simulation studies have shown that Computerized Adaptive Testing (CAT) could overcome these weaknesses. We studied the applicability (using the measures participation rate, satisfaction, and efficiency) and the validity of CAT in routine PCH practice. METHODS: We analyzed data on 461 children aged 10-11 years (response 41%), who were assessed during routine well-child examinations by PCH professionals. Before the visit, parents completed the CAT and the Child Behavior Checklist (CBCL). Satisfaction was measured by parent- and PCH professional-report. Efficiency of the CAT procedure was measured as number of items needed to assess whether a child has serious problems or not. Its validity was assessed using the CBCL as the criterion. RESULTS: Parents and PCH professionals rated the CAT on average as good. The procedure required at average 16 items to assess whether a child has serious problems or not. Agreement of scores on the CAT scales with corresponding CBCL scales was high (range of Spearman correlations 0.59-0.72). Area Under Curves (AUC) were high (range: 0.95-0.97) for the Psycat total, externalizing, and hyperactivity scales using corresponding CBCL scale scores as criterion. For the Psycat internalizing scale the AUC was somewhat lower but still high (0.86). CONCLUSIONS: CAT is a valid procedure for the identification of emotional and behavioral problems in children aged 10-11 years. It may support the efficient and accurate identification of children with overall, and potentially also specific, emotional and behavioral problems in routine PCH.

Comparing three short questionnaires to detect psychosocial problems among 3 to 4-year olds.

BACKGROUND: Validated questionnaires help community pediatric services to identify psychosocial problems. Our aim was to assess which of three short questionnaires was most suitable for this identification among pre-school children. METHODS: We included 1,650 children (response 64 %) aged 3-4 years undergoing routine well-child health assessments in 18 services across the Netherlands. Child healthcare professionals (CHPs) interviewed and examined children and parents. Parents were randomized regarding filling out the Strengths and Difficulties Questionnaire (SDQ) or the KIPPPI, a Dutch-origin questionnaire. In addition, all filled out the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) and the Child Behavior Checklist (CBCL). We assessed the internal consistency and validity of each questionnaire, with CBCL and treatment status as criteria, and the degree to which each questionnaire could improve identification based solely on clinical assessment. RESULTS: The internal consistency of the total problems scale of each questionnaire was satisfactory, Cronbach's alphas varied between 0.75 and 0.98. Only the SDQ discriminated sufficiently between children with and without problems as measured by the CBCL (sensitivity = 0.76 at a cut-off point with specificity = 0.90), in contrast to the other two questionnaires (with sensitivity indices varying between 0.51-0.63). Similar results were found for the treatment status criterion, although sensitivity was lower for all questionnaires. The SDQ seemed to add most to the identification of psychosocial problems by CHPs, but the differences between the SDQ and the ASQ:SE were not statistically significant. CONCLUSIONS: The SDQ is the best tool for the identification of psychosocial problems in pre-school children by community paediatric services.

Punishment and reward in parental discipline for children aged 5 to 6 years: prevalence and groups at risk.

OBJECTIVE: In this study we examined the use and predictors of different discipline practices by parents of children aged 5 to 6 years. METHODS: We obtained cross-sectional data for a nationally representative Dutch sample of children aged 5 to 6 years within the setting of routine well-child visits provided to the entire population. A total of 1630 children participated (response rate, 84%). Before the visit, parents completed a questionnaire with questions about their approach to discipline (punishment and rewards). Chi-square tests and logistic regression analyses were used to examine associations between discipline practices and child, parent, and family factors. RESULTS: Parental punishment prevalence was 21.9% for spanking and 80.3% for other punishment practices, such as time-outs. The prevalence of rewards as a discipline strategy was 32.2% for granting privileges and 86.3% for cuddling/complimenting. Multivariate logistic regression analyses showed that spanking was more likely in families in which the mothers have low and medium levels of education and in families of non-Dutch ethnicity. Other punishment practices (eg, time-outs, verbal reprimands, and holding) were more likely in families of Dutch ethnicity. Granting privileges was more likely in families of non-Dutch ethnicity, who lived in large cities, whose income was below the poverty level, in unemployed families, and in small families. Cuddling and complimenting were more likely in families with a high maternal educational level, in families of Dutch ethnicity, and in small families. CONCLUSIONS: These findings show the importance of considering social and economic factors when identifying and supporting parents with parenting/rearing challenges.

Three questionnaires to detect psychosocial problems in toddlers: a comparison of the BITSEA, ASQ:SE, and KIPPPI.

OBJECTIVE: Validated questionnaires can improve the identification of psychosocial problems in community pediatric services. Our aim was to assess which of 3 short questionnaires-the Brief Infant-Toddler Social and Emotional Assessment (BITSEA), the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE), and the KIPPPI (Brief Instrument Psychological and Pedagogical Problem Inventory)-was most suitable as a routine screening tool for identification among toddlers. METHODS: We included 2106 parents (response rate 81%) of children aged 6, 14, or 24 months at routine well-child visits in 18 services across the Netherlands. Child health care professionals interviewed and examined children and parents. Parents were randomized to complete either the BITSEA or the KIPPPI; all filled out the ASQ:SE and the Child Behavior Checklist. For each questionnaire, we assessed the internal consistency, validity with Child Behavior Checklist-Total Problems Score (CBCL-TPS) as a criterion, and added value to identification compared to clinical assessment alone. RESULTS: Cronbach's alphas of the total scales varied between 0.46 to 0.91. At the ages of 6 and 14 months, none of the instruments studied had adequate validity. At the age of 24 months, only the BITSEA discriminated sufficiently between children with and without problems (sensitivity = 0.84 at specificity = 0.90), but not the other 2 questionnaires (with sensitivity indices varying between 0.53 and 0.60 at similar specificity). The BITSEA at this age offered slightly higher added value to the identification of psychosocial problems by child health care professionals. CONCLUSIONS: For toddlers aged 6 and 14 months, no questionnaire is sufficiently valid to support the identification of psychosocial problems. The BITSEA is the best short tool for the early detection of psychosocial problems in 2-year-old children.

Characteristics of the strengths and difficulties questionnaire in preschool children.

OBJECTIVES: Validated questionnaires help the preventive child healthcare (PCH) system to identify psychosocial problems. This study assesses the psychometric properties and added value of the Strengths and Difficulties Questionnaire (SDQ) for the identification of psychosocial problems among preschool-aged children by PCH. METHODS: We included 839 children (response 66%) 3 to 4 years of age undergoing routine health assessments in 18 PCH services across the Netherlands. Child healthcare professionals interviewed and examined children and parents. Before the interview, parents completed the SDQ and the Child Behavior Checklist (CBCL). We assessed the internal consistency, the scale structure, and validity (correlation coefficients, sensitivity, and specificity), with CBCL and treatment status as criteria, and the degree to which the SDQ could improve identification solely on the basis of clinical assessment. RESULTS: The internal consistency of the SDQ total difficulties score was good (Cronbach's α, 0.78), but it was worse for some subscales of the SDQ (range, 0.50-0.74). The area under the receiver operating characteristic curve using the CBCL as a criterion was 0.94 (95% confidence interval 0.91-0.97), and sensitivity and specificity were 0.79 and 0.93, respectively. The SDQ added information to the clinical assessment; the odds ratio was 36.48 for added information by using the CBCL as a criterion. CONCLUSIONS: The SDQ is a valid tool for the identification of psychosocial problems in preschool-aged children by PCH. However, the low reliability of some SDQ subscales does not justify use of these subscales for decisions about further treatment.

Early detection of psychosocial problems in children aged 5 to 6 years by preventive child healthcare: has it improved?

OBJECTIVE: To assess whether the quality of identification of psychosocial problems by preventive child healthcare professionals (CHPs) in children aged 5-6 years has improved after a series of nationwide interventions. STUDY DESIGN: We analyzed data about 8440 children aged 5-6 years who were assessed during routine well-child visits by CHPs (response rates, 85%-90%). Of these children, 4339 were assessed before the interventions. Parents completed the Child Behavior Checklist (CBCL) and CHPs reported on psychosocial problems that they identified in children. The agreement between identification of psychosocial problems by CHPs and parent-reported problems on the CBCL were assessed before and after the nationwide interventions. RESULTS: CHPs identified psychosocial problems in 22%-28% of all children. Identification of psychosocial problems by CHPs was much more likely in children with an elevated CBCL total problems score than in others (OR: 4.65, 95% CI: 3.28-6.58). The quality of identification by CHPs did not improve after the interventions, the OR for improvement was 0.81 (95% CI: 0.57-1.15). CONCLUSIONS: The quality of problem identification by CHPs has not improved. CHPs still miss many cases with parent-reported problems on the CBCL. Additional efforts are needed to improve early identification of psychosocial problems.

A comparison of four scoring methods based on the parent-rated Strengths and Difficulties Questionnaire as used in the Dutch preventive child health care system.

BACKGROUND: Validated questionnaires can support the identification of psychosocial problems by the Preventive Child Health Care (PCH) system. This study assesses the validity and added value of four scoring methods used with the Strengths and Difficulties Questionnaire (SDQ) for the identification of psychosocial problems among children aged 7-12 by the PCH. METHODS: We included 711 (of 814) children (response: 87%) aged 7-12 undergoing routine health assessments in nine PCH services across the Netherlands. Child health professionals interviewed and examined children and parents. Prior to the interview, parents completed the SDQ and the Child Behaviour Checklist (CBCL), which were not shown to the professionals. The CBCL and data about the child's current treatment status were used as criteria for the validity of the SDQ. We used four SDQ scoring approaches: an elevated SDQ Total Difficulties Score (TDS), parent-defined difficulties, an elevated score for emotional symptoms, conduct problems or hyperactivity in combination with a high impairment score, and a combined score: an elevated score for any of these three methods. RESULTS: The Cohen's Kappa ranged from 0.33 to 0.64 for the four scoring methods with the CBCL scores and treatment status, generally indicating a moderate to good agreement. All four methods added significantly to the identification of problems by the PCH. Classification based on the TDS yielded results similar to more complicated methods. CONCLUSION: The SDQ is a valid tool for the identification of psychosocial problems by PCH. As a first step, the use of a simple classification based on the SDQ TDS is recommended.

Use of the Pediatric Symptom Checklist for the detection of psychosocial problems in preventive child healthcare.

BACKGROUND: Early detection and treatment of psychosocial problems by preventive child healthcare may lead to considerable health benefits, and a short questionnaire could support this aim. The aim of this study was to assess whether the Dutch version of the US Pediatric Symptom checklist (PSC) is valid and suitable for the early detection of psychosocial problems among children. METHODS: We included 687 children (response 84.3%) aged 7-12 undergoing routine health assessments in nine Preventive Child Health Services across the Netherlands. Child health professionals interviewed and examined children and parents. Before the interview, parents completed an authorised Dutch translation of the PSC and the Child Behavior Checklist (CBCL). The CBCL and data on the child's current treatment status were used as criteria for the validity of the PSC. RESULTS: The consistency of the Dutch PSC was good (Cronbach alpha 0.89). The area under the ROC curve using the CBCL as a criterion was 0.94 (95% confidence interval 0.92 to 0.96). At the US cut-off (28 and above), the prevalence rate of an increased score and sensitivity were lower than in the USA. At a lower cut-off (22 and above), sensitivity and specificity were similar to that of the US version (71.7% and 93.0% respectively). Information on the PSC also helped in the identification of children with elevated CBCL Total Problems Scores, above solely clinical judgment. CONCLUSION: The PSC is also useful for the early detection of psychosocial problems in preventive child healthcare outside the USA, especially with an adjusted cut-off.