Screening for Behavioral and Emotional Problems in Children and Adolescents With Congenital or Acquired Limb Deficiencies James W. Varni, PhD, Yoshio Setoguchi, MD with chronic physical handicaps have been found to be at risk for psychological and social adjustment problems. Accurately identifying in a timely manner those physically handicapped children who are functioning at clinically significant levels of maladjustment may aid in preventing further psychosocial morbidity. The parents of 111 children and adolescents with congenital/acquired limb deficiencies completed the Child Behavior Checklist as a screening instrument to facilitate the identification of behavioral and emotional problems and social incompetence. Based on normalized T scores, the children manifested significantly greater behavioral and emotional problems and lower social competence than the normative community sample. Twenty-three percent of the children were reported to function in the clinically significant maladjustment range for behavioral and emotional problems; 14% were reported in the social maladjustment range. Correlations between parent report and child, adolescent, and teacher reports of adjustment ranged from r values of .23 to .41. The findings are discussed in terms of the "new hidden morbidity" in pediatric practice. \s=b\ Children

(AJDC. 1992;146:103-107)

limb deficiencies in children congenital in with acquired amputation due disease Mostorigin, children less are

to

or

prevalent.1 Although physical trauma being with chronic physical handicaps have been shown to be at increased risk for behavioral and emotional

problems,2,3

the variability observed in adaptation suggests wide indi¬ vidual differences.3 This at-risk status in combination with the observed individual variance in adaptation indicates the need to identify accurately those physically handi¬ capped children who are functioning at clinically signifi¬ cant levels of maladjustment. The prevalence of behavioral and emotional problems among children seen in pediatrie primary care has been

Accepted for publication From the Child

October 7, 1991.

Amputee Prosthetics Project, Department of Pe-

diatrics, UCLA, and Shriners Hospital for Crippled Children-Los

Angeles.

Reprint requests to Child Amputee

ment

Prosthetics Project, Departof Pediatrics, UCLA, 10833 Le Conte Ave, 12-311 MDCC, Los

Angeles,

CA 90024-1752 (Dr

Varni).

estimated at 16%,4 whereas the overall prevalence esti¬ mates of moderate to severe disorder from epidemiolog¬ ica! studies range from 14% to 20% .5 These observed rates

of psychological maladjustment have resulted in the con¬ cern for screening children in need of mental health ser¬ vices seen in pediatrie primary care.6 Clearly, the need for screening physically handicapped children for behavioral and emotional problems is no less great, and arguably is even greater given their at-risk status.2,3 Similar to laboratory tests for biological disease, identi¬

fying psychosocial morbidity in a patient population requires a standardized test with established reliability and validity. However, even when such a test exists, for the test to be ordered there must first be the recognition that the patient population is at increased risk for dys¬ function. The clinical decision-making process in ordering a laboratory test is often initiated by patient or parent re¬ port of signs and symptoms indicative of potential dys¬ function. While such a system of practice seems to work reasonably well for biological disease,7 there are a number of reasons why it is inadequate for identifying behavioral and emotional problems in children. In a study screening for behavioral and emotional problems in children 7 to 11 years of age attending pedi¬ atrie primary care clinics in a health maintenance organi¬ zation, parents completed the Child Behavior Checklist (CBCL) as the screening instrument.8 Approximately 25%

of the children were identified by the CBCL as malad¬ and 95% of those identified children and their parents were given a detailed standardized assessment interview. Based on the standardized interview with the parent in this subsample, 11.8% of the children were di¬ agnosed as maladjusted. In contrast, pediatricians diag¬ nosed one or more behavioral and emotional problems in 5.6% of the children during the primary care visit. The pediatricians' clinical assessments of behavioral and emo¬ tional problems were highly specific (true-negative rate) in that 84% of children assessed as not maladjusted had no psychological disorder. In contrast, the pediatricians' assessments showed low sensitivity (true-positive rate) in that only 17% of the children with behavioral or emotional problems were identified, resulting in 83% of the cases being incorrectly identified (ie, 83% "hidden morbidity rate"). Costello et al8 termed this continuing underiden-

justed,

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tification of behavioral and emotional problems in stan¬ dard pediatrie practice as the "new hidden morbidity," in contrast to the previous term, "hew morbidity."4,6 Thus, the concern is "the extent to which the new morbidity is still a hidden morbidity. "8

Screening for behavioral and emotional problems in children and adolescents with congenital or acquired limb deficiencies.

Children with chronic physical handicaps have been found to be at risk for psychological and social adjustment problems. Accurately identifying in a t...
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