Parent reports of children's emotional and behavioral problems in a low- and middle- income country (LMIC): An epidemiological study of Nepali schoolchildren.

BACKGROUND: As epidemiological data on child mental health in low- and middle-income countries are limited, a large-scale survey was undertaken to estimate the prevalence and amount of child emotional and behavioral problems (EBP) in Nepal as reported by the parents. METHODS: 3820 schoolchildren aged 6-18 years were selected from 16 districts of the three geographical regions of Nepal, including rural, semi-urban and urban areas. We used the Nepali version of the Child Behavior Checklist (CBCL)/6-18 years as screening instrument. Comparisons of child problems between genders and between the seven largest castes and ethnic groups were carried out by analysis of variance. Prevalence was computed based on American norms. RESULTS: Adjusted prevalence of Total Problems was 18.3% (boys: 19.1%; girls:17.6%). The prevalence of internalizing problems was higher than externalizing problems. The mean scores of Total, Externalizing, and Internalizing problems were 29.7 (SD 25.6), 7.7 (SD 8.0), and 9.1 (SD 8.1), respectively. The Khas Kaami (Dalit) group scored the highest, and the indigenous Tharu group scored the lowest on all scales. In the Mountains and Middle Hills regions, problem scores were higher in the rural areas, whereas in the Tarai region, they were higher in the urban areas. CONCLUSION: The prevalence and magnitude of emotional and behavioral problems in Nepali children were found to be high compared to findings in meta-analyses worldwide. Problem scores varied according to gender, castes /ethnic groups, and living areas. Our findings highlight the need for a stronger focus on child mental problems in a low-and middle-income country like Nepal.

Physical health and emotional and behavioral problems in maltreated children according to family economic status: Health problems of maltreated children in Korea.

ABSTRACT: Low family income is a risk factor for child maltreatment. However, there has been no comparative study on the association between child maltreatment and family income. The objective of this study was to investigate the physical health and emotional and behavioral problems of maltreated children according to the economic status of their family.Cross-sectional nationwide studyData from 2012 to 2014 was extracted from the Korean National Child Abuse Registry (age <18 years) operated by the National Child Protection Agency (NCPA). Demographic characteristics and 34 physical health and emotional/behavioral problems of maltreated children were compared by family economic status. Family economic status was classified into 2 groups: families receiving the National Basic Livelihood Guarantee (NBLG) and those not receiving the guarantee (non-NBLG group).A total of 17,128 children were registered in the system. Mean age was 9.3 years (SD 4.8 years), 44.4% were females, and 29.2% were in the NBLG group. Poor hygiene, anxiety, and attention deficit were frequently reported physical and emotional health problems. Common behavioral problems included running away, rebelliousness/impulsivity/aggressiveness, maladjustment in school, learning problems at school, and frequent unauthorized absenteeism and truancy. Physical health problems (7 of 8 items) occurred more often in the NBLG group, and behavioral problems (6 of 17 items) occurred more often in the non-NBLG group.Children in Korea who are maltreated have different physical health, emotional, and behavioral problems depending on their family income level. These results can be useful in approaching the recognition of and interventions for child maltreatment.

Economic Return on Investment of Parent Training Programmes for the Prevention of Child Externalising Behaviour Problems.

Economic models to inform decision-making are gaining popularity, especially for preventive interventions. However, there are few estimates of the long-term returns to parenting interventions used to prevent mental health problems in children. Using data from a randomised controlled trial evaluating five indicated parenting interventions for parents of children aged 5-12, we modeled the economic returns resulting from reduced costs in the health care and education sector, and increased long-term productivity in a Swedish setting. Analyses done on the original trial population, and on various sized local community populations indicated positive benefit-cost ratios. Even smaller local authorities would financially break-even, thus interventions were of good value-for-money. Benefit-cost analyses of such interventions may improve the basis for resource allocation within local decision-making.

The opioid epidemic, neonatal abstinence syndrome, and estimated costs for special education services.

Children whose mothers used or misused opioids during their pregnancies are at an increased risk of exhibiting cognitive or behavioral impairments in the future, which may result in identifiable disabilities that require special education services in school. The costs associated with these additional educational services, however, have remained unknown. Using data from available empirical work, we calculated a preliminary set of cost estimates of special education and related services for children diagnosed with neonatal abstinence syndrome (NAS). We estimated these costs for a single cohort of children from the Commonwealth of Pennsylvania with a diagnosis of NAS. The resulting cost estimates were $16,506,916 (2017 US$) in total educational services provisions, with $8,253,458 (2017 US$) of these costs attributable to the additional provision of special education services. This estimate includes both opioid use during pregnancy that was linked to NAS in general and NAS that resulted specifically from prescription opioid use. We estimate the total annual education costs for children born in Pennsylvania with NAS associated with maternal use of prescription opioids to be $1,012,506 (2017 US$). Of these costs, we estimate that $506,253 (2017 US$) are attributable to the additional provision of special education services. We detail the calculation of these cost estimates and provide an expanded set of estimates for additional years of special education services (3-year, 5-year, and 13-year, or the K-12 educational time frame). We conclude with a discussion of limitations and suggestions for future work.

Eyberg Child Behavior Inventory (ECBI): Normative data, psychometric properties, and associations with socioeconomic status in Finnish children.

Assessment of behavioral disorders is one of the most commonly encountered tasks in child psychiatry. The Eyberg Child Behavior Inventory (ECBI) is a widespread measurement tool used for assessing conduct problems, though the psychometric properties of the tool have varied in different samples. In this study, the ECBI was evaluated in a Finnish population based sample of children aged 4 to 12 years (n = 1,715). Factor structure and internal consistency of the ECBI and associates of behavioral problems in Finnish children were evaluated. The results showed that a unidimensional one-factor solution for the ECBI intensity scale was the best fit for the data. The ECBI mean scores were considerably higher in our sample compared to other Nordic countries. Boys scored higher than girls on both ECBI scales, and the mean scores decreased with child's age. Socioeconomic status (SES) was weakly connected to the ECBI scores. Our results highlight the need for country specific reference norms in order to improve the clinical utility of evidence-based measures for assessing conduct problems.

Reducing Preschool Behavior Problems in an Urban Mental Health Clinic: A Pragmatic, Non-Inferiority Trial.

OBJECTIVE: This pragmatic, randomized, non-inferiority trial compared the effectiveness and cost of group-based parent management training with mastery-based individual coaching parent management training in a low-income, predominantly African American sample. METHOD: Parents seeking treatment for their 2- to 5-year-old children's behavior problems in an urban fee-for-service child mental health clinic were randomized to the Chicago Parent Program (CPP; n = 81) or Parent-Child Interaction Therapy (PCIT; n = 80). Consent followed clinic intake and diagnostic assessment and parent management training was delivered by clinicians employed at the clinic. Primary outcome measures were externalizing child behavior problems, assessed at baseline and postintervention follow-up, using the Child Behavior Checklist (CBCL) and average per-participant treatment cost. RESULTS: Data from 158 parents were analyzed. Most were mothers (75.9%), African American (70.3%), and economically disadvantaged (98.7% Medicaid insured). Of children, 58.2% were boys, and mean age was 3.6 years (SD 1.03). Based on CBCL scores, behavior problems improved in the 2 conditions (Cohen d = 0.57 for CPP and 0.50 for PCIT). CPP was not inferior to PCIT (90% CI -1.58 to 4.22) at follow-up, even after controlling for differences in treatment length (90% CI -1.63 to 4.87). Average per-participant treatment cost was higher for PCIT (mean $2,151) than for CPP (mean $1,413, 95% CI -1,304 to -170). CONCLUSION: For parents of young children living in urban poverty, CPP is not inferior to PCIT for decreasing child behavior problems. CPP requires less time to complete and costs a third less than PCIT. CLINICAL TRIAL REGISTRATION INFORMATION: Early Parenting Intervention Comparison (EPIC); https://clinicaltrials.gov/; NCT01517867.

Distance-Delivered Parent Training for Childhood Disruptive Behavior (Strongest Families™): a Randomized Controlled Trial and Economic Analysis.

Disruptive behavior disorders are prevalent in youth, yet most children with disruptive behavior do not have access to timely, effective treatment. Distance-delivered service (e.g., via telephone, Internet) can overcome several barriers to care. This study tested the effectiveness of a 12-week parent training program, Strongest Families™ Parenting the Active Child, delivered via written material, skill-based videos, and telephone coaching sessions, as compared to usual care in reducing child externalizing behavior. Participants were 172 primary caregivers of a 6- to 12-year-old (29% girls; M age = 8.5 years) recruited from community children's mental health clinics. Participants were randomized to either Strongest Families™ or usual care and completed measures of child externalizing behavior, parenting practices, parent distress, and intervention services consumed at baseline and 5-, 10-, 16-, and 22-months post-baseline. Growth curve analysis showed significant reductions in externalizing behavior in both conditions over time. Improvements were significantly greater at 10 months in the Strongest Families™ condition (d = 0.43). At 22 months, however, the differences were not significant and small in magnitude (d = -0.05). The intervention decreased inconsistent discipline significantly more than usual care. Parents in both conditions showed significant reductions in distress. We also conducted a cost-effectiveness analysis to assess the value for money of the Strongest Families™ program versus usual care. Distance parent training is a promising way to increase access to, and reduce costs associated with, mental health care for families with a child with disruptive behavior.

Maternal sociodemographic factors differentially affect the risk of behavioral problems in Brazilian and Italian preterm toddlers.

The main aim of the present study was to examine differences in behavioral problems in toddlers born very preterm in Brazil and Italy. The sample comprised 154 toddlers (18-24 months of age) born very preterm, including 76 toddlers from Brazil and 78 toddlers from Italy. The Child Behavior Checklist was used to assess behavioral problems. Specific sociodemographic factors (i.e., maternal age at childbirth and maternal education) and neonatal factors (i.e., gestational age, sex, and length of hospitalization) were tested as potential mediators of country-related differences in behavioral problems. Brazilian toddlers presented more internalizing, externalizing, and total behavioral problems compared with their Italian counterparts. The effect of country on the toddlers' internalizing and total behavioral problems was mediated by maternal age at childbirth and education. Independent effects of country, maternal age at childbirth, and maternal education emerged for externalizing behavioral problems. No significant effect emerged for neonatal variables. These findings suggest that sociodemographic factors, in addition to country-related differences, should be considered when assessing the risk of behavioral problems in preterm toddlers.

Preventing enduring behavioural problems in young children through early psychological intervention (Healthy Start, Happy Start): study protocol for a randomized controlled trial.

BACKGROUND: Behavioural problems are common in early childhood, and can result in enduring costs to the individual and society, including an increased risk of mental and physical illness, criminality, educational failure and drug and alcohol misuse. Most previous research has examined the impact of interventions targeting older children when difficulties are more established and harder to change, and have rarely included fathers. We are conducting a trial of a psychological intervention delivered to families with very young children, engaging both parents where possible. METHODS: This study is a two-arm, parallel group, researcher-blind, randomized controlled trial, to test the clinical effectiveness and cost-effectiveness of a parenting intervention, Video Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD) for parents of young children (12-36 months) at risk of behavioural difficulties. VIPP-SD is an evidence-based parenting intervention developed at Leiden University in the Netherlands which uses a video-feedback approach to support parents, particularly by enhancing parental sensitivity and sensitive discipline in caring for children. The trial will involve 300 families, who will be randomly allocated into either an intervention group, who will receive the video-feedback intervention (n = 150), or a control group, who will receive treatment as usual (n = 150). The trial will evaluate whether VIPP-SD, compared to treatment as usual, leads to lower levels of behavioural problems in young children who are at high risk of developing these difficulties. Assessments will be conducted at baseline, and 5 and 24 months post-randomization. The primary outcome measure is a modified version of the Preschool Parental Account of Child Symptoms (Pre-PACS), a structured clinical interview of behavioural symptoms. Secondary outcomes include caregiver-reported behavioural difficulties, parenting behaviours, parental sensitivity, parental mood and anxiety and parental relationship adjustment. An economic evaluation will also be carried out to assess the cost-effectiveness of the intervention compared to treatment as usual. DISCUSSION: If shown to be effective, the intervention could be delivered widely to parents and caregivers of young children at risk of behavioural problems as part of community based services. TRIAL REGISTRATION: ISRCTN Registry: ISRCTN58327365 . Registered 19 March 2015.

Valuation of Child Behavioral Problems from the Perspective of US Adults.

OBJECTIVE: To assess preferences between child behavioral problems and estimate their value on a quality-adjusted life year (QALY) scale. METHODS: Respondents, age 18 or older, drawn from a nationally representative panel between August 2012 and February 2013 completed a series of paired comparisons, each involving a choice between 2 different behavioral problems described using the Behavioral Problems Index (BPI), a 28-item instrument with 6 domains (Anxious/Depressed, Headstrong, Hyperactive, Immature Dependency, Anti-social, and Peer Conflict/Social Withdrawal). Each behavioral problem lasted 1 or 2 years for an unnamed child, age 7 or 10 years, with no suggested relationship to the respondent. Generalized linear model analyses estimated the value of each problem on a QALY scale, considering its duration and the child's age. RESULTS: Among 5207 eligible respondents, 4155 (80%) completed all questions. Across the 6 domains, problems relating to antisocial behavior were the least preferred, particularly the items related to cheating, lying, bullying, and cruelty to others. CONCLUSIONS: The findings are the first to produce a preference-based summary measure of child behavioral problems on a QALY scale. The results may inform both clinical practice and resource allocation decisions by enhancing our understanding of difficult tradeoffs in how adults view child behavioral problems. Understanding US values also promotes national health surveillance by complementing conventional measures of surveillance, survival, and diagnoses.

The great recession and behavior problems in 9-year old children.

This article examines associations between the Great Recession and 4 aspects of 9-year olds' behavior-aggression (externalizing), anxiety/depression (internalizing), alcohol and drug use, and vandalism-using the Fragile Families and Child Wellbeing Study, a longitudinal birth cohort drawn from 20 U.S. cities (21%, White, 50% Black, 26% Hispanic, and 3% other race/ethnicity). The study was in the field for the 9-year follow-up right before and during the Great Recession (2007-2010; N = 3,311). Interview dates (month) were linked to the national Consumer Sentiment Index (CSI), calculated from a national probability sample drawn monthly to assess consumer confidence and uncertainty about the economy, as well as to data on local unemployment rates. Controlling for city-fixed effects and extensive controls (including prior child behavior at age 5), we find that greater uncertainty as measured by the CSI was associated with higher rates of all 4 behavior problems for boys (in both maternal and child reports). Such associations were not found for girls (all gender differences were significant). Links between the CSI and boys' behavior problems were concentrated in single-parent families and were partially explained by parenting behaviors. Local unemployment rates, in contrast, had fewer associations with children's behavior, suggesting that in the Great Recession, what was most meaningful for child behavior problems was the uncertainty about the national economy, rather than local labor markets.

Socioeconomic deprivation is an independent risk factor for behavioral problems in children with epilepsy.

AIM: The aim of this study was to examine whether socioeconomic deprivation in children with epilepsy (CWE) increases risk for behavioral problems independent of seizure factors. METHODS: A cross-sectional study was done in which parents of children attending a specialist epilepsy clinic were invited to complete a child behavior checklist (CBCL) questionnaire about their child. Medical and sociodemographic data on CWE were obtained through their pediatric neurologists. Home postal code was used to obtain quintiles of Scottish Index of Multiple Deprivation 2012 (SIMD2012) scores for individuals. Lower (1-3) quintiles correspond to higher socioeconomic deprivation. Regression analysis was used to investigate whether a lower quintile was an independent risk factor for scores >63 (significant behavioral problem). RESULTS: Parents of 87 children (42 male, mean age of 10.5years) were enrolled. Fifty-nine percent had total scores >63. A higher proportion of children from quintiles 1-3 compared to those from quintiles 4-5 had externalizing (49% vs. 25%, p=0.02) and total (54% vs. 30%, p=0.02) scores >63. Adjusted OR of quintiles 1-3 vs. 4-5 for scores >63=14.8, 95% CI=3.0, 68.0. Fewer children with scores >63 and from quintiles 1-3 were known to the child and adolescent mental health service (CAMHS) compared to those in quintiles 4-5 (p=0.01). INTERPRETATION: Socioeconomic deprivation was an independent risk factor for behavioral problems in CWE. Children with epilepsy and behavioral problems who lived in socioeconomically deprived areas received less help.

Cost-effectiveness of intensive home treatment enhanced by inpatient treatment elements in child and adolescent psychiatry in Germany: A randomised trial.

BACKGROUND: Admission rate to child and adolescent mental health inpatient units in Germany is high (54,467 admissions in 2013), resources for providing necessary beds are scarce. Alternative pathways to care are needed. Objective of this study was to assess the cost-effectiveness of inpatient treatment versus Hot-BITs-treatment (Hometreatment brings inpatient-treatment outside), a new supported discharge service offering an early discharge followed by 12 weeks of intensive support. METHODS: Of 164 consecutively recruited children and adolescents, living within families and being in need of inpatient mental health care, 100 patients consented to participate and were randomised via a computer-list into intervention (n=54) and control groups (n=46). Follow-up data were available for 76 patients. Primary outcome was cost-effectiveness. Effectiveness was gathered by therapist-ratings on the Children's Global Assessment Scale (CGAS) at baseline (T1), treatment completion (T2) and an 8-month-follow-up (T3). Cost of service use (health care costs and non-health care costs) was calculated on an intention-to-treat basis at T2 and T3. RESULTS: Significant treatment effects were observed for both groups between T1/T2 and T1/T3 (P<0.001). The Hot-BITs treatment, however, was associated with significantly lower costs at T2 (difference: -6900.47€, P=0.013) and T3 (difference: -8584.10€, P=0.007). Bootstrap cost-effectiveness ratio indicated that Hot-BITs was less costly and tended to be more effective at T2 and T3. CONCLUSIONS: Hot-BITs may be a feasible cost-effective alternative to long inpatient stays in child and adolescent psychiatry. Further rigorous evaluations of the model are required. ( REGISTRATION NUMBER: ISRCTN02672532, part 1, Current Controlled Trials Ltd, URL: http://www.controlled-trials.com).

Socioeconomic inequalities in parent-reported and teacher-reported psychological well-being.

OBJECTIVE: To determine whether there are differences in the social gradient of parent-reported and teacher-reported child psychological well-being. DESIGN: Secondary data analysis comparing ratings of child psychological well-being (Strengths and Difficulties Questionnaire, SDQ) in the UK Millennium Cohort Study at 7 years by socioeconomic circumstances (SEC). A number of measures of SEC were tested; results are reported for maternal education. From a sample of 13,168 singletons who participated at the age of 7 years, complete data were available for 8207 children. RESULTS: There was a social gradient in SDQ scores reported by parents and teachers, with 'borderline/abnormal' scores more prevalent in children with lower-educated mothers. However, the gradient was more marked in parent report compared with teacher report, and discrepancies between parent and teacher reports were greatest for children from higher SECs. CONCLUSIONS: The social gradient in child psychological well-being, although present, was weaker in teacher report compared with parent report. This may be because children behave differently in school and home settings, or parents and teachers demonstrate reporting bias.

Effect of multiple chronic diseases on health care expenditures in childhood.

OBJECTIVES: To examine multiple chronic conditions and related health care expenditures in children. METHODS: Retrospective cohort study of all dependents of Mayo Clinic employees aged 0-17 on Jan 1, 2004 with continuous health benefits coverage for 4 years (N=14,727). Chronic conditions, health care utilization, and associated expenditures were obtained from medical and pharmacy claims. RESULTS: The most prevalent chronic conditions were asthma/chronic obstructive pulmonary disease (12%), allergic rhinitis (11%), and behavior problems (9%). The most costly conditions were congenital anomalies, asthma/chronic obstructive pulmonary disease, and behavior problems ($9602, $4335, and $5378 annual cost per child, respectively). Annual health care expenditures increased substantially with the number of chronic conditions, and a small proportion of children with multiple chronic conditions accounted for a large proportion of health care costs. In addition, those with multiple chronic conditions were more likely to persist in the top 10th percentile spender group in year-to-year spending. CONCLUSION: Children with multiple chronic conditions accounted for a large proportion of health care expenditures. These children were also likely to persist as high spenders in the 4-year time frame. Further research into effective ways to manage the health care delivery for children with multiple chronic conditions is needed.

Reducing child conduct disordered behaviour and improving parent mental health in disadvantaged families: a 12-month follow-up and cost analysis of a parenting intervention.

The effectiveness of the Incredible Years Basic parent programme (IYBP) in reducing child conduct problems and improving parent competencies and mental health was examined in a 12-month follow-up. Pre- to post-intervention service use and related costs were also analysed. A total of 103 families and their children (aged 32-88 months), who previously participated in a randomised controlled trial of the IYBP, took part in a 12-month follow-up assessment. Child and parent behaviour and well-being were measured using psychometric and observational measures. An intention-to-treat analysis was carried out using a one-way repeated measures ANOVA. Pairwise comparisons were subsequently conducted to determine whether treatment outcomes were sustained 1 year post-baseline assessment. Results indicate that post-intervention improvements in child conduct problems, parenting behaviour and parental mental health were maintained. Service use and associated costs continued to decline. The results indicate that parent-focused interventions, implemented in the early years, can result in improvements in child and parent behaviour and well-being 12 months later. A reduced reliance on formal services is also indicated.

Use of medication prescribed for emotional or behavioral difficulties among children aged 6-17 years in the United States, 2011-2012.

Mental health problems are common chronic conditions in children (1-3). Medication is often prescribed to treat the symptoms of these conditions (4-7). Few population-based studies have examined the use of prescription medication to treat mental health problems among younger as well as older school-aged children (8-10). This report describes the sociodemographic characteristics of children aged 6-17 years prescribed medication or taking medication during the past 6 months for emotional or behavioral difficulties, and describes parental reports of the perceived benefit of this medication.

Study protocol for a comparative effectiveness trial of two parent training programs in a fee-for-service mental health clinic: can we improve mental health services to low-income families?

BACKGROUND: Untreated behavioral and mental health problems beginning in early childhood are costly problems affecting the long-term health and wellbeing of children, their families, and society. Although parent training (PT) programs have been demonstrated to be a cost-effective intervention modality for treating childhood behavior problems, they have been less effective for children from low-income and underserved racial and ethnic populations. The purpose of this randomized trial is to compare the effectiveness, cost, and social validity of two manualized evidence-based PT programs that were developed and tested on different populations and employ different delivery models: (1) The Chicago Parent Program (CPP), a group-based program developed in collaboration with a community advisory board of African-American and Latino parents; and (2) Parent-Child Interaction Therapy (PCIT), an individualized parent-child coaching model considered to be 'the gold standard' for parents of children with externalizing behavior problems. METHODS: This trial uses an experimental design with randomization of parents seeking behavioral treatment for their 2- to 5-year-old children at a mental health clinic in Baltimore, MD (80% African-American or multi-racial; 97% receiving Medicaid). Using block randomization procedures, 262 parents are randomized to CPP or PCIT. Clinicians (n=13) employed in the mental health clinic and trained in CPP or PCIT are also recruited to participate. Primary outcomes of interest are reductions in child behavior problems, improvements in parenting, perceived value of the interventions from the perspective of parents and clinicians, and cost. Parent distress and family social risk are assessed as modifiers of treatment effectiveness. We hypothesize that CPP will be at least as effective as PCIT for reducing child behavior problems and improving parenting but the programs will differ on cost and their social validity as perceived by parents and clinicians. DISCUSSION: This is the first study to compare the effectiveness of a PT program originally designed with and for parents from underserved racial and ethnic populations (CPP) against a well-established program considered to be the 'the gold standard' (PCIT) with a high-risk population of parents. Challenges related to conducting a randomized trial in a fee-for-service mental health clinic serving urban, low-income families are discussed. TRIAL REGISTRATION: NCT01517867.

Healthcare use and costs associated with children's behavior problems.

The objective of the study was to investigate associations between severity of behavior problems, specific symptom domains with healthcare use and costs in school-aged children. A cross-sectional study using data from the 10-year follow-up of two population-based birth cohorts was conducted on four rural and urban communities in Germany. There were 3,579 participants [1,834 boys (51%), 1,745 girls (49%)] on average aged 10.4 years. The severity levels (normal, at risk, abnormal) and symptom domains of behavioral problems were assessed by parent-reported strengths and difficulties questionnaire (SDQ).The outcomes were medical use categories (physicians, therapists, hospital, and rehabilitation), medical costs categories and total direct medical use and costs (calculated from parent-reported utilization of healthcare services during the last 12 months). Total direct medical costs showed a graded relationship with severity level (adjusted p < 0.0001). Average annual cost difference in total direct medical costs between at risk and normal total difficulties was Euro () 271 (SD 858), and 1,237 (SD 2,528) between abnormal and normal total difficulties. A significant increase in physician costs showed between children with normal and at risk total difficulties (1.30), and between normal and abnormal total difficulties (1.29; p < 0.0001). Between specific symptom domains, children with emotional symptoms showed highest costs for physicians, psychotherapist, and hospitalization as well as total direct medical costs. Children with hyperactivity/inattention showed highest costs for therapists and emergency room costs. Healthcare use and costs are related to the severity of child behavior problems. In general, children's costs for psychotherapy treatments have been low relative to general medical treatments which may indicate that some children with behavioral problems did not get appropriate care. To some degree, medical conditions may be attributable to some of the high hospitalization costs found in children with emotional symptom.