Using the Pediatric Symptom Checklist (PSC) in the pediatrician's office

However, primary care clinicians face numerous barriers, and frequently do not provide children appropriate mental health treatments or referrals to specialists.⁴ Studies indicate that less than 30% of children with substantial dysfunction are recognized by primary care clinicians.⁵ And nationally, referral rates of children seen by pediatricians to mental health services range from 1% to 4%.⁶ Barriers to providing needed psychosocial services to children include insufficient training, the stigma felt by the child and family, very limited or no reimbursement, and lack of a brief screening method that not only identifies children at risk, but also fits seamlessly into the workflow of a pediatric primary care office.³

The Pediatric Symptom Checklist (PSC) was developed as a screening tool to help pediatricians improve recognition of children with psychosocial dysfunction who could thus benefit from further evaluation. The PSC is a one-page questionnaire that can be completed in approximately three minutes, and reflects parents' impressions of their children's psychosocial functioning. The standard parent-completed PSC form consists of 35 items that are rated as "never," "sometimes," or "often present," and scored 0, 1, or 2, respectively. The scores for each question are added together to yield a single total score, which can be tabulated in under a minute. The PSC is public domain, so can be used free of charge.

Use in office practice

The PSC has been translated into more than a dozen languages, including English, Spanish, Chinese, Hmong, Creole, Dutch, German, and Swahili. A pictorial version of the PSC is available in both English and Spanish. There is a self-report PSC for youth (PSC-Y) available in English, Spanish, French, Haitian-Creole and Brazilian-American Portuguese, and a shorter PSC-17 with subscales, all available at no cost at http://psc.partners.org/psc_order.htm.⁷

In many practices, the PSC is given out at registration during the annual visit, or mailed ahead as part of a pre-visit packet. Clinicians may score the form themselves or have a receptionist attach the scored form to the paperwork related to other screenings (eg, height, weight, hematocrit) they hand to the pediatrician.

For children aged 6 through 16, the cutoff score is 28 or higher (28=impaired; 27=not impaired). The cutoff score recommended is based on large national samples in the US where a score of 28+ identifies about 12% of children as being at risk.⁸ For children ages 3 to 5, the scores on school-related items 5, 6, 17, and 18 are ignored since they are not relevant; a total score based on the 31 remaining items is completed, with the cutoff score for these younger children being 24 or greater.

Conceptually, the PSC is based on the finding that children who have substantial dysfunction in one area commonly have difficulty functioning in other areas. A positive PSC score usually reflects that a child's parents have marked "often" in multiple areas of concern. Scores above the cut point on the PSC occur in 5% to 20% of most populations. This range reflects the fact that economic and cultural factors impact psychosocial functioning and reporting. For example, we have found the children living in poverty who face many stressors are more likely than middle-class children to score positive on the PSC.

Different cultures may have different cutoff scores. Pediatricians whose practices serve a distinct culture should begin by collecting data on a number of cases to ascertain the accuracy of a cut-off score of 28 for their populations. For example, in Japan, a recommended cutoff score is 17, in European samples it is 24 or 25, and in a newly immigrant Mexican-American sample it is just 12.

If a pediatrician sees 50 patients aged 4 to 16 a week, approximately five (10%) will have positive screens. One or two of these patients may already be known to the physician, and be receiving mental health services. The other three should be asked several questions about the major areas of their daily life-school performance, family relationships, activities, friendships, and their mood (eg, self-esteem, depression). This follow-up interview should last 10 to 15 minutes, and yield enough information to assess the next step-watchful waiting, a follow-up pediatric visit, or mental health referral.

The PSC has been validated by comparing it to the longer Child Behavior Checklist (CBCL), comparing PSC scores to the Children's Global Assessment Scale (CGAS) ratings of impairment, and the presence of psychiatric disorder in a variety of pediatric and subspecialty settings representing diverse socioeconomic backgrounds. The PSC is validated for the full range of pediatric practices, and has been found to be a well-accepted choice as an instrument for screening.⁹