Screening for psychosocial problems in 5–6-year olds: a randomised controlled trial of routine health assessments

Abstract

Objective

Children's psychosocial problems are often not identified accurately. The present study addresses the effect of training of Child Health Doctors (CHDs) in a structured method to identify psychosocial problems on the accuracy of this identification in children aged 5–6.

Method

The study was a randomised controlled trial (RCT) with a baseline and two follow-up measurements. A volunteer sample of 58 CHDs participated, randomly assigned to intervention or control condition. CHDs selected a population-based sample of 5–6-year-old children (n = 6375).

Results

The first follow-up showed that sensitivity had improved by 9% and specificity by 5% in the intervention condition, especially in children with severe problems (odds ratio = 3.7; 95% confidence interval: 1.2–11.8). The second follow-up showed a decrease in sensitivity and specificity in both conditions.

Conclusion

The training improves identification of psychosocial problems, especially severe ones, although the availability of time and resources also influences the accuracy with which psychosocial problems are identified.

Introduction

Psychosocial problems, i.e., behavioural and emotional problems, are highly prevalent among children. Various studies have reported that prevalence ranges between 13 and 27% [1], [2], [3], [4], [5], [6].

There is evidence that these problems may be reduced by secondary prevention programs and early treatment [7], [8], [9], [10], [11]. A review by Durlak et al. showed that both behavioural and cognitive–behavioural preventive interventions are effective treatments for children with psychosocial problems, for both internalizing and externalizing problems [7]. A review by Bryant et al. showed modest effects in parent-focused interventions, teacher-focused interventions, and child-focused interventions for preschoolers with aggressive and disruptive behaviour [8]. While early treatment is wholly dependent on the accurate identification of children with psychosocial problems, identification procedures are currently too inaccurate [3], [4], [5], [12], [13]. In a previous study, Dutch Child Health Professionals (CHPs; i.e., doctors and nurses working in Preventive Child Health Care) identified no psychosocial problems in 43% of children whose parents had reported serious problems during routine health assessments [4]. This means that a lot of children with psychosocial problems lack early treatment or adequate support from CHPs [4]. Clearly, there is room for CHPs to improve their screening performance. Although there are several screening instruments for identifying psychosocial problems, identification of psychosocial problems remains inaccurate [14], [15], [16], [17], [18]. One reason for this is that physicians use these tools infrequently when screening psychosocial problems in children [19]. Furthermore, most of these instruments are parent-completed questionnaires and although these questionnaires provide reliable information, they can support but not replace the interview with the physician, in which a number of sources (parent, child, observation) are used to identify problems. According to Wildman et al., one of the best predictors of identification of psychosocial problems is whether mothers disclose concerns about their child's psychosocial functioning to the physician [20]. Disclosure of these concerns can be enhanced if physicians master some communication skills, but also if physicians are able to systematically categorize signals from parents and child regarding psychosocial problems [21]. Training physicians in these skills might help them to improve the identification of psychosocial problems [21], [22].

While training might help them do so, there is no evidence on its effectiveness. Our study, therefore, set out to assess the effect of a structured method for systematically identifying psychosocial problems in children aged [5], [6]. The method was developed by the Preventive Child Health Care Service in Breda, a city in the southern Netherlands, in cooperation with the psychology department of the University of Utrecht. An earlier non-experimental study in the Breda region had indicated that training CHPs in this method improved the identification of behavioural and emotional problems in children by CHPs [23].

The aim of the present study is to address the effect of training of Child Health Doctors (CHDs) in this structured method, on the accuracy of identification of behavioural and emotional (furtheron: psychosocial) problems, overall and for moderate and severe problems. In The Netherlands, preventive child health care is an important low-threshold service for the early identification of psychosocial problems in children. Such care is provided on an unsolicited basis to all children living in The Netherlands, by CHPs working in the Preventive Child Health Care Services. As part of this system, more than 90% of all children undergo three to four assessments by a CHP during their school careers [4]. Because part of these assessments involves an interview on psychosocial problems, the Preventive Child Health Services are an ideal setting for the early identification of psychosocial problems and for improving this identification.