The Role of Parents in the Detection of Developmental and Behavioral Problems

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The

Role

of

Parents

in

the

Detection

of

Developmental

and

Behavioral

PEDIATRICS Vol. 95 No. 6 June 1995 829

Problems

Frances Page Glascoe, PhD*; and Paul H. Dworkin, MD

ABSTRACT. Objective. The success of early

identifica-tion of children with developmental and behavioral

problems is influenced by the manner in which

pedia-tricians elicit, recognize, and select clinical information

and derive appropriate impressions. Parents are ready

sources of clinical information, and they can be asked to

provide two broad types of data: appraisals, including

concerns, estimations, and predictions; and descriptions,

including recall and report. The purpose of this article is

to help pediatricians make optimal use of clinical

infor-mation from parents to increase the accuracy of clinical

judgment in detecting children with developmental and

behavoral problems.

Design. Review of 78 research articles and tests relying

on parent information from pediatric, psychological, and

education literature.

Results and Conclusion. There are several formats for

eliciting parental information that are superior in terms

of accuracy and ease of evocation. Specifically, parents’

concerns and good-quality standardized parent report

measures such as the Child Development Inventories

capitalize best on parents’ observations and insights into

their children. In combination, these two types of

paren-tal information offer an effective method for the early

detection of behavioral and developmental problems in

primary-care settings. Pediatrics 1995;95:829-836;

par-ents’ concerns, developmental screening, developmental surveillance, behavior problems.

The Committee on Children with Disabilities of

the American Academy of Pediatrics recently has

emphasized the importance of the early

identifica-tion of children with developmental disabilities.1 In

addition to leading to effective therapy for

condi-tions for which definitive treatment is available,

early intervention for conditions that cannot be

re-versed improves children’s outcomes and enables

families to obtain resources for successful

function-ing.2 Furthermore, such early detection is mandated

by legislation (Public Law 99-457, reauthorized as

Public Law 102-I 19, The Individuals with

Disabili-ties Education Act).

Conservative estimates suggest that 12% to 16% of

American children have behavioral and emotional

disorders.3 The Committee on Psychosocial Aspects

From the *Division of Child Development, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN; and the Depart-ment of Pediatrics, University of Connecticut School of Medicine, Hartford,

CT.

Received for publication Aug 4, 1994; accepted Sep 27, 1994.

Reprint requests to (F.P.G.) Division of Child Development, Department of

Pediatrics, Vanderbilt University, 2100 Pierce Ave. Nashville, TN 37232.

of Child and Family Health of the American

Acad-emy of Pediatrics has urged pediatricians to be

con-cerned with the early detection of children’s

behav-ioral problems.4 Recent initiatives such as Bright

Futures, a collaborative project of the Maternal and

Child Health Bureau, the Medicaid Bureau, and the

American Academy of Pediatrics to develop national

guidelines for child health supervision, have

empha-sized the importance of early detection of

psychoso-cial risks.2

Despite widespread agreement regarding the

im-portance of the early detection of developmental and

behavioral problems in children, there is no

consen-sus as to how such early identification is optimally

performed. Current professional practice reflects the

variety of opinions on how best to monitor children’s

development and behavior. Techniques include

re-viewing milestones with parents; using an informal

collection of age-appropriate tasks selected from

var-ious developmental schedules; relying on clinical

judgment based on history, physical examination,

and office observation; and performing formal

screening with a standardized test.6

Past research has documented the infrequent use

of developmental and behavioral screening tests by

pediatricians.11 Yet when physicians rely on

subjec-tive impressions, their estimates of children’s

devel-opmental and behavioral status are often

maccu-rate.128 Almost half of children with developmental

disabilities are not identified by their

pediatri-cians.15’6 Furthermore, numerous studies confirmed

significant underidentification by pediatricians of

children with behavioral and emotional

prob-lems.’7’8

The approach to detecting developmental and

be-havioral problems currently practiced by the

major-ity of primary-care pediatricians is most consistent

with the process termed surveillance. As defined by

the British, this is a flexible, continuous process

whereby knowledgeable professionals perform

skilled observations of children during the provision

of health care.11 The components of surveillance

in-dude eliciting and attending to parents’ opinions

and concerns, obtaining a relevant developmental

and behavioral history, making accurate and

infor-mative observations of children, and sharing

opin-ions and concerns with other relevant professionals,

such as preschool teachers.

Efforts to improve surveillance and promote more

effective and earlier detection of developmental and

behavioral problems in children must acknowledge

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

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830 PARENTS AND DEVELOPMENTAL AND BEHAVIORAL PROBLEMS

common errors in clinical reasoning.19 The success of

early identification is influenced by the manner in

which pediatricians elicit, recognize, and select

din-ical information and derive appropriate impressions.

Certain types of clinical information, such as parents’

opinions and concerns, seem especially predictive of

children’s developmental and behavioral status. An

abundance of research suggests that when

pediatri-cians incorporate parental data, clinical impressions

increase in accuracy. Thus, the purpose of this article

is to review research on the two broad types of

clinical information parents can provide about

chil-dren’s developmental and behavioral status: parents’

appraisals, including concerns, estimations, and

pre-dictions; and parents’ descriptions, including recall

and report. Each of these constructs is defined in

Table I and described in detail below. The rationale

is to help pediatricians make optimal use of clinical

information from parents to increase the accuracy of

clinical judgment in detecting developmental and

behavioral problems in children.

PARENTS’ APPRAISALS

Parents’ appraisals or opinions of their children’s

development and behavior can be expressed in a

variety of ways. Research has focused on three of

these: estimations, predictions, and concerns. Each

has distinct advantages and disadvantages.

Estimations

Some of the earliest research on parents’ abilities to

judge how well their children were developing

re-quired parents to provide numerical estimates of

children’s developmental age(s), usually elicited by a

question such as, “Even though your child is 36

months old, about how old does she seem to you?”

Parents’ age estimates were, in most studies,

con-verted to ratio quotients and compared with the

measured IQs. Moderate to high correlations were

produced, ranging from .53 to #{149}93#{149}2023Other studies

extended the clinical relevance of such findings by

reporting the percentage of parents who gave

esti-mations falling into the same SD as the measured IQ.

These studies found that parents were between 60%

and 75% sensitive in providing IQ estimates, and that

their specificity in estimating IQs that fell in the

range of normal was consistently I00%.21,23-25 Other

researchers required parents to estimate

develop-mental ages within each domain.20’’26 In the more

careful and detailed of these studies, parents

pro-vided more accurate estimates of cognitive, motor,

self-help, and academic skills than expressive and

receptive language skills. However, the researchers

noted that parents are more likely than strangers to

observe the full complement of children’s language

skills, and that parental overestimates of language

skills may be a function of children’s greater

willing-ness to verbalize at home.2#{176}

Although research on parents’ estimations is

promising, the clinical applicability of the findings

continues to be a question for the following reasons:

(I) all studies used populations at high risk for

de-velopmental problems (families seeking services

through developmental evaluation centers), a

condi-tion likely to inflate the sensitivity and positive

pre-dictive value of estimations;27 (2) differences in

wording make several studies less than comparable

(eg, those that encouraged parents to estimate ages in

both years and months produced more accurate

re-sults than when parents were only encouraged to

estimate in years;2#{176}(3) parents do not seem to think

uniformly in terms of age estimates and often need

prompting and examples before they are able to offer

age estimates; (4) obtaining estimates across several

developmental domains is necessary for identifying

children with apparent difficulties; for example, one

study showed that estimates less than chronologic

age in the domains of receptive language, self-help,

global development, and behavior are required for

identifying children with emotional and/or

behav-ioral problems, whereas estimates less than

chrono-logic age in fine motor, speech and language, and

gross motor skills and behavior are needed for

iden-tifying children with developmental difficulties;27

and (5) although one study found that parents

re-gardless of differences in education and

socioeco-nomic status were able to provide useful age

esti-mates,27 several studies found that more educated

parents were better able than those without high

school educations to produce accurate estimates-a

finding not associated with other methods of

elicit-ing parents’ concerns.20’21 More research on the topic

of parental estimations is needed.

Predictions

A second, although substantially less researched,

approach to eliciting parents’ opinions requires them

to predict how their children will function in the

future. Although research on this topic is limited,

one study asked two groups of parents, one with

2-year old children with cerebral palsy or mental

retardation and a second group whose 2-year-old

children were developing normally, to predict how

well their children would function at 18 years of age

on items from the Vineland Adaptive Behavior Scale,

a measure of communication, social, self-help, and

TABLE 1. Definitions of Terms

Construct Definition of Task

Parents’ appraisals

Estimations Predictions

Concerns

Parents’ descriptions Recall

Report

Parents’ evaluations and opinions of children’s developmental and behavioral status

Age equivalents expressed numerically for each developmental domain

Prognostications of future functioning, usually of kindergarten performance or competence as an adult Judgments about children’s current developmental/behavioral stage

Nonjudgmental depictions of children’s skills

Historical, time-dated description of past accomplishments

Depiction of current skills

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ARTICLES 831

motor skills.29 At first glance, this approach seems

highly inaccurate, because parents of children with

disabilities predicted that their children would

func-tion within the average range.2#{176}However, parents of

children developing normally indicated that their

children would function well above average, a

find-ing dubbed by researchers as “presidential

syn-drome.” Although all parents overestimate how their

children will function in the future, there were clear

differences between parents of children with and

without disabilities.29 Other studies used parents’

current assessments of their children as predictors of

outcome measured several years later. For example,

Broussard and Hartner30’3’ required parents to

com-pare their 6-week old infants with the average infant

on nine dimensions, including ease of feeding,

con-soling, sleeping habits, and so forth. Four and one

half years later, children were administered a battery

of psychological and developmental measures. Of

the children determined to have significant

prob-lems, 70.6% had been rated by their parents as

sig-nificantly more difficult than the average infant,

whereas only 23.5% of the children without

prob-lems had received adverse parental ratings.

Al-though such studies of prediction are few in number

and suffer from either substantial attrition or the use

of atypical populations, the findings again suggest

that parents’ appraisals have at least some validity

in reflecting the presence or absence of childhood

problems.

Concerns

Many recent studies have assessed parents’

con-cerns in the form of verbal evaluations of children’s

status. In contrast to parental reports (see below),

parents’ concerns are typically expressed in a

sen-tence or two, through which parents’ judgments of

the quality of their children’s behavior and

develop-ment are visible. Two sets of studies have assessed

various aspects of concerns: concerns about

emo-tional and behavioral status and concerns about

de-velopment.

Emotional and Behavioral Concerns

A number of studies noted that parents waiting for

pediatric care often had concerns about their

chil-dren’s behavioral and emotional status.32’33

Subse-quent studies explored the accuracy of parents’

con-cerns about emotional and behavioral issues. Dulcan

et aP7 showed that when parents raised concerns or

when concerns were elicited, physicians were 13

times more likely to not only notice psychiatric

prob-lems but also to make needed referrals. Similarly,

Glascoe et al, using a sample of 1- through

6-year-old children and their parents waiting for routine

pediatric care, found that 70% of children who failed

a standardized measure of behavioral and emotional

problems could be identified by parents’ concerns

about behavioral and emotional status. Mulhern et

al,35 using a group of children referred to a

develop-mental and behavioral evaluation clinic, found even

higher rates of concordance between parental

con-cerns and behavioral problems; 87% of children with

attention-deficit hyperactivity disorder had parents

with concerns about impulsiveness, inattention, or

overactivity. Although this high rate of sensitivity

may be attributable to the use of a population with a

greater probability of behavioral problems, the

find-ings corroborate other studies in showing a close

relationship between parental concerns about

emo-tional and behavioral problems and true psychiatric

and behavioral disturbance.

Developmental Concerns

Hickson et al33 found that parents waiting with

their children for routine, well child pediatric care

were most likely to mention to pediatricians

con-cerns about their children’s mental development,

in-cluding slower learning, learning problems, etc. A

follow-up study by Glascoe et aPe’ showed that such

concerns were accurate indicators of true

develop-mental problems. Of 100 0- through 6-year-old

chil-dren waiting for well or return visits, 20 were found

to have undiagnosed developmental problems. Of

the 20, 80% had parents with developmental

con-cerns. One of the more interesting results was that

not all concerns reflected true developmental

prob-lems. Only concerns about speech and language, fine

motor, or global functioning (eg, “she can’t do what

other kids can”; “He’s slow and behind other kids”)

tended to reflect measurable difficulties. Concerns in

other areas, ie, social, self-help, and gross motor

function (“He’s bossy”; “She won’t do for herself”;

“She’s not good at soccer”) were not found to be

sensitive indicators of developmental problems

(as-suming, in the case of gross motor concerns, that

pediatricians have ruled out neurologic problems). A

subsequent study corroborated the importance of

specific developmental concerns with 1 57, 6- through

77-month-old children waiting for well child

pediat-ric care, 28% of whom were found to have

undiag-nosed speech and language problems.37 Of this

group, 72% of parents had concerns about speech

and language development. Similarly, parents’

spe-cific concern about their children’s hearing was a

highly sensitive indicator of hearing problems.38

Di-amond39 extended these findings by probing the

pre-dictive validity of specific parental concerns. A

ran-dom sample of 150 of 800 6- through 62-month-old

children attending a health fair were assessed 4 years

later. Fifty percent of the children whose parents had

raised concerns about language, learning, motor,

speech, or cognitive and academic skills were having

substantial school difficulty, defined as special class

placement, in-grade retention, or participation in

re-medial reading classes.

Wording of Questions About Concerns

The above studies support the value of parental

concerns and also illustrate the importance of

con-sidering concerns as multifaceted-some concerns

are clearly better current and future predictors of

developmental and behavioral problems than others.

Thus, careful questioning is needed to elicit and

cat-egorize parental concerns. Glascoe et a136 found that

parents responded well to the question, “Please tell

me any concerns about the way your child is

behav-ing, learning, and developing.” However, use of the

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832 PARENTS AND DEVELOPMENTAL AND BEHAVIORAL PROBLEMS

words “worries” or “problems” deterred responses,

because many parents were reluctant to endorse

terms that were potentially ominous or significant.’1#{176}

Many parents were not familiar with the word

“de-velopment,” but pairing “learning and

develop-ment” facilitated comprehension and

communica-tion.36 Still, many parents do not think about

development in the same manner as professionals, as

a range of domains. Thus, in subsequent studies by

Glascoe and colleagues, a second question was

added to ensure more thoughtful responses: “Any

concerns about how she . . . understands what you

say? . . . talks? . . . makes speech sounds? . . . uses

hands and fingers to do things? . . . uses arms and

legs? . . .behaves? . . . gets along with others? . . . is

learning to do things for himself or herself . . . is

learning preschool and school skills?” Other

re-searchers also found it necessary to question parents

more than once about their concerns and to prompt

them to think about developmental domains. For

example, researchers with the Iowa High-Risk Infant

Follow-Up Program used the Parents’ Concerns

Sur-vey, which includes items eliciting specific concerns

about development, school readiness, and health and

growth.41

The Meaning of Parental Concerns

Most studies on parental concerns illustrate a

strong parallel relationship between the type of

con-cern and the subsequent diagnosis. This suggests

that concerns could be taken at face value, and that

the type of complaint is a strong indicator of the type

of problem children may have. However, Oberklaid

et al,42 using a population of preschool children

re-ferred for diagnostic testing, showed that parental

concerns about behavior and emotional well-being

often reflected deficits in developmental, rather than

behavioral, areas. Glascoe43 corroborated these

find-ings in a randomly selected group of children in

regular day care settings. Children with cognitive

delays (IQs less than 79) often had parents with

concerns about behavior or language. In fact, 83% of

children with global delays could be identified by

parental concerns about behavior and/or language.

Both studies illustrate that parents may not

hypoth-esize about the reasons why their children “won’t do

what I ask” and may not consider, for example, that

their child might not: (1) hear well; (2) have the

receptive language skills to comprehend the request;

and/or (3) have the cognitive skills to execute it.

Responding to Parental Concerns

Because of the high levels of sensitivity of certain

parental concerns, levels that approach standards for

screening test sensitivity (approximately 80%), it is

tempting to think that pediatricians simply could

elicit parental concerns and, if significant (ie,

con-cerns about language, cognition, or fine-motor

skills), could make referrals for subsequent

work-ups. However, referral on the basis of parental

con-cerns may not be the most appropriate response. In

almost all studies, parental concerns had specificities

that are less than desirable (90% or greater accurate

identification of children without problems),’ which

means that there would exist an excessively high

overreferral rate.

Similarly, parents’ concerns have limited positive

predictive value-parents clearly worry more about

their children’s behavior and development than is

warranted. The predictive value of concerns ranged

from 40% to 55%. Stickler et al45 corroborated this

general tendency in an article comparing the high

frequency of parental worries with the substantially

lower, actual risks of events such as abduction,

can-cer, and reactions to immunization. These findings

have tremendous implications for pediatricians,

be-cause they suggest that the best response to parental

concerns may be to seek additional information with

which to triangulate a concern.

Influences on Parents’ Concerns

That parents’ concerns produce a high number of

overreferrals raises a number of questions about

what influences their concerns. Pediatricians often

wonder whether parents with limited education or

parenting experience are as able as other parents to

raise valid concerns. Several studies addressed these

questions with surprising results. Dulcan et aP7

found that children’s age, sex, social class, and race

and health status did not affect the probability that

parents would consult with a physician about

psy-chiatric concerns. Other studies also showed an

ab-sence of a relationship between the accuracy of

par-ents’ concerns and their levels of education or

parenting experience (defined as the number of

chil-dren in the home and the subject child’s birth

or-der).’36’37’43 Although these findings may seem

coun-terintuitive, parents were found to derive their

concerns by comparing their children with others

(eg, “I see what other kids can do and then see if he

can”). Because the thinking skills involved in

mak-ing comparisons involve the simple processes of

matching and discriminating, parents, regardless of

their levels of education or parenting experience,

seem equally able to raise important concerns.

One influence on parents’ concerns is the settings

in which concerns are elicited. Glascoe43 used a

sam-ple of children drawn from day care centers and

found that their parents’ concerns resulted in

sub-stantially more overreferrals than did the concerns of

parents in pediatric settings. Specificity dropped

from 72% to 94% in pediatric offices34’36’37 to 47% in

day care programs. Not only did parents whose

chil-dren received day care have more health concerns

than parents in with children in pediatric settings (all

of whom were interviewed after the pediatric

en-counter), but the health concerns were found to

cor-relate strongly with concerns about development

and behavior. One possible explanation is that

pedi-atricians’ abilities to address health issues reduces

parents’ medical fears and, hence, their overall

anx-iety levels. This may enable parents to offer

devel-opmental and behavioral concerns that more

accu-rately reflect true developmental and behavioral

status. Thus, caution should be exercised when

elic-iting concerns outside pediatric settings and when

relying on these for referral decisions.

Clinicians and researchers also have questioned

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ARTICLES 833

the extent to which concerns reflect parental anxiety

or parents’ own mental health problems, rather than

true problems in their children. Most but not all

studies suggest that a significant proportion of

van-ance in parental concerns and perceptions of

child-hood problems is determined by existing parental

and family histories of mental health problems

(in-cluding depression, anxiety, and panic disorder) and

mental health treatment or adjudication, including

current maternal stresses such as recent divonce.4755

Although these findings suggest that parental

dis-tress may be a factor in overreferrals (an assumption

that has not been tested directly), it is also well

established that parental mental health problems are

a strong contributor to both developmental and

be-havioral problems in children.56 Most of the above

studies found that depressed, anxious, or distressed

parents were more likely to have children with

psy-chiatnic and other problems. Furthermore, in one

study, pediatricians were more likely to determine

the presence of a true psychiatric problem when

parents were either anxious or depressed.17 This

sug-gests that a parent with a significant developmental

or behavioral concern who is also obviously

dis-tressed may be more likely, not less likely, to offer

accurate clinical information. Nevertheless,

pediatni-cians should respond somewhat differently to such

parents and provide not only developmental and

behavioral assessment for children and referrals as

indicated but also recommend mental health and/or

social services for parents.

PARENTS’ DESCRIPTIONS

Parents’ descriptions of their children’s

develop-ment and behavior that do not involve appraisal or

judgment include recall and report.

Recall

Tasks in which parents are asked to remember

events such as developmental milestones,

child-rear-ing practices, or the content of recent pediatric visits

have a thorough lack of reliability,5769 although a

recent study provided some support for parents’

abilities to recall birth events.60 Parents’ recall of

developmental milestones, however, tends to stray

in the direction of their beliefs and prior conceptions.

For example, parents with permissive beliefs about

child rearing tend to recall that their children were

toilet trained much later than they actually were,

whereas parents with authoritarian child-rearing

be-liefs recalled that their children were toilet trained

much earlier than records indicated. For this reason,

recall should either be avoided, gathered with

lim-ited expectations for its veracity, and/or

cornobo-rated when necessary with medical or other records.

Report

In contrast, parental report, a task that relies on

descriptions of children’s current achievements, is

well known for its reliability and validity under the

conditions described below.

Reliability

A parental report can never be more reliable than

the quality of the measure itself. Questions that were

clearly and carefully written were answered more

reliably than items that were vague and lacking in

detail61 (a finding that also may contribute to the

veracity of recall). Questions that use a recognition

format (eg, “Does your child use any of the following

words . . .“) rather than an identification format (eg,

“What words does your child say?”) also improve

reliability.62 Parental reporting also has been shown

to have a sufficiently high degree of short-term

(usu-ally 1-week) test-retest reliability to meet desirable

standards for psychologic and educational tests.63

Correlation coefficients typically range from .80 to

.99P Parental reporting is also shown to have high

levels of stability, as indicated by high correlation

coefficients for longer intervals of time.4#{176}

Validity

The issue of accuracy in parental reports has been

long debated. Several studies found that parental

reports produce slightly higher estimates of

chil-dren’s skills than is apparent on professional

assess-ments relying on direct elicitation. This finding led

many professionals to assume that parents’ tend to

overestimate children’s abilities. Other researchers

have debated this conclusion and suggested that

par-ents may report positively about skills that children

demonstrate inconsistently and only in familiar

en-vironments.23 Such inconsistency is a hallmark of

new learning-recently learned skills require

addi-tional practice before they are generalizable to new

settings. Thus, it is probable that professional

assess-ments tend to underestimate children’s ski1ls.65’

Some test developers dealt with this phenomena by

asking parents to state whether children demonstrate

skills “all of the time, some of the time, or rarely,” an

approach that is thought to heighten congruence

be-tween professional and parental observations.

De-spite the differences between parent and professional

observations (which is, in fact, helpful in identifying

skills that are emerging but not yet mastered), most

studies show that the agreement between the two is

consistently high and ranges from 75% to 95%#{149}62.67.68

Influences on Parental Reports

Are there differences in the accuracy of parental

reports given different family characteristics?

Re-search on this issue is equivocal. Some studies found

that parents of lower socioeconomic status were less

accurate, partially because they tended to omit more

questions on written inventories.69 This may be a

function of reading problems and is a finding that

should prompt practitioners to offer interviews as

opposed to self-administered formats to parents with

limited education. Some measures circumvent

read-ing problems by encouraging parents to take tests

home to complete in preparation for a visit devoted

to scoring and interpretation.1#{176} Typically, parents

with poor reading (or English language) skills can

find others to assist them in completing protocols

correctly.

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834 PARENTS AND DEVELOPMENTAL AND BEHAVIORAL PROBLEMS

Ultimately, the validity of a parental report is

de-pendent on the quality of the items, including: (1) the

extent to which items reflect the constructs of

devel-opment (ie, the various domains and subdomains

(such as expressive versus receptive language); and

(2) in the case of screening measures, the extent to

which groups of items identify children at risk for

specific kinds of problems. Thus, parent reporting

works well when researchers have attended to the

wording of items carefully and have tested items for

their consistency, clarity, content, reliability, and

va-lidity-mn short, created a standardized measure.7#{176}

For this reason, it greatly behooves practitioners to

rely on standardized parent report screening tests,

rather than resorting to informal checklists or

ques-tionnaires. Table 2 lists some of the better parent

report measures (those that meet or approach

stan-dards for screening tests (sensitivity approximating

80% and specificity approaching 90%).

COMMENT

Of the various approaches to obtaining

good-qual-ity information from parents, eliciting their concerns

and obtaining their reports seem the best researched

and the most accurate and effective. In making use of

parental information, pediatric practitioners may be

better able to detect important problems as early as

possible. In addition to promoting early

identifica-tion of developmental and behavioral problems, an

emphasis on parents as important sources of

infor-mation offers additional benefits. The role of parents

as partners in the process of child health supervision

is inherently emphasized, and the interest of the

pediatric practitioner in the child’s overall

function-ing is stressed. Many parents do not assume that

practitioners are interested in discussing children’s

behavioral, psychosocial, or developmental

prob-lems.23 Also, within the busy office setting, using

combinations of parental concern and reporting is an

efficient approach to sort children into those

requir-ing further assessment and intervention from those

merely in need of routine, age-appropriate

anticipa-tory guidance, and developmental promotion.

Research on parents’ concerns suggests that this

valuable source of clinical information functions

much like a prescreening test, through which a

sub-set of children can be identified to whom more

corn-plete screening measures should be administered.

Thus, the correct response when presented with a

significant parent concern is to gather more data

about the child. A variety of approaches to data

gathering may be used, including taking in-depth

histories, interviewing parents (and teachers),

corn-pleting developmental and behavioral

question-naires, administering a standardized developmental

screening test, and directly observing parent and

child behavior in the office setting.11’19

Although many screening tests rely on direct

mea-surement of children’s skills, such measurement is

not always practicable in pediatric offices, where

children may be too refractory or too ill to fully

demonstrate their skills. Further, practitioners’ time

is often limited. Screening measures that rely on

parental reports-descriptions of children’s specific

skills-are especially helpful because they: (1)

elim-mate the need for obtaining children’s cooperation

and effort; (2) provide a more thorough and

exten-sive sampling of children’s skills than is typically

obtained with direct elicitation measures; and (3)

have flexible administration methods, via interviews,

over the telephone, taken home by parents and

corn-pleted in preparation for a second appointment,

self-administered in waiting rooms, etc. It should be

em-phasized that parental concern and reporting are two

distinct and separate pieces of clinical information

that do not overlap completely. For example, parents

with concerns about language development did not

uniformly describe their children’s language skills as

substantially deviant from the normal population.

Conversely, some parents who did not raise concerns

about their children’s behavior nevertheless

en-dorsed a significant number of significant behavior

problems on a behavioral and emotional screen.

De-spite the seeming inconsistency between parents’

concerns and reporting, the failure of these two

sources of clinical information to overlap perfectly

has helpful implications for pediatricians. It is

possi-ble to intersect parental concerns with parental

re-ports to obtain brief, highly accurate indicators of

children’s true developmental and behavioral

sta-tus-indicators that can be easily and flexibly

ob-tamed within busy pediatric practices.

A parent with a significant concern, whose child

does not have a significant developmental or

behav-TABLE 2. Sample of Quality, Broad- Band Measur es Relying on Parental Report

Test Name Age Range Description

Eyberg Child Behavior Inventory71 2-11 y 36 items sampling a range of childhood behavior problems including

internalizing/externalizing difficulties

Pediatric Symptoms Checklist72 4-16 y 35 items sampling a range of difficult behaviors and emotions

Infant Development Inventory73 0-15 mo 60 items, produces cutoff scores of 30% delay relative to chronologic age in 5

developmental domains

Early Child Development Inventory> 15-36 mo 60 items sampling all domains, produces a single general development index with cutoff score at 30% delay

Preschool Development Inventory> 36-72 mo 60 items sampling all domains with emphasis on preschool and school skills, produces a single cutoff at 30% delay

Child Development Inventory76 15-72 mo 270 items, producing cutoffs in each domain tied to I .3, 1 .5, and 2.0 SD below the mean

Infant Monitoring Questionnaire 4-36 mo 35 items in all domains, separate forms at 4, 8, 12, 16, 20, 24, 30, and 36 months

Self-Administered Questionnaire for Parents 12 items identifying parents with probable depression, substance abuse,

Psychosocial Screening2’ history of abuse as a child

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ARTICLES 835

ioral problem, may be a parent who is noticing

sub-clinical or subtle manifestations of a problem, which,

if left unattended, might burgeon into a diagnosable

condition. For example, Glascoe et aP found that

parents with concerns about behavior, whose

chil-dren passed behavior screening, had children with

substantially larger numbers of behavior problems

(mean = 10) than did parents without concerns

(mean = 6). Although these results have not been

corroborated with other types of parental concerns

(eg, language, fine-motor, and cognitive

develop-ment), there exists a strong possibility that parents

with unsubstantiated concerns are noticing and

re-acting to problems that are present but subtle and

hence highly likely to respond quickly to early

inter-vention. In any case, such parents would seem to be

prime candidates for developmental promotion and

anticipatory guidance, as well as for careful

monitor-ing of the child’s functioning. These parents may

benefit from and respond well to suggestions from

pediatricians about stimulation activities, parenting

texts, and classes.

Summary

Parents can offer a wealth and variety of valuable

information about children’s development. This

in-formation can be elicited in varying ways, with

sev-eral formats clearly emerging as superior in accuracy

and ease of evocation. Specifically, parents’ concerns

and quality standardized parent report measures,

such as the Child Development Inventories,

capital-ize best on parents’ observations and insights about

their children. In combination, these two types of

parental information offer an effective method for

early detection of behavioral and developmental

problems in primary-care settings.

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DON’T BOTHER ME WITH THE FACTS ...

The

gap

between medical science and medical practice is well established.

Studies in the United States and elsewhere report that there is little relationship

between published research and medical practice . . . Disarmingly, practitioners

frequently report that they are aware of new findings or guidelines but have not

changed their practices.

REFERENCE

1. Greer AL. Scientific knowledge and social consensus. Contr Cli,i Trials. 1994;15:431-436.

Submitted by Student

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1995;95;829

Pediatrics

Frances Page Glascoe and Paul H. Dworkin