Developmentally and Culturally Appropriate Screening in Primary Care: Development of the Behavioral Health Checklist

Mental health problems are among the most prevalent chronic conditions of youth (Van Cleave, Gortmaker, & Perrin, 2010). The American Academy of Pediatrics has asserted that primary care providers have an important role in providing services to children with mental health concerns (Foy, Kelleher, Laraque, & American Academy of Pediatrics Task Force on Mental Health., 2010). As a first step, it is critical for primary care providers to screen for behavioral and emotional concerns to identify children who may need further evaluation and intervention services (Bell, Johnson, Myers, & Patrick, 2010; Navon, Nelson, Pagano, & Murphy, 2001). The American Academic of Pediatrics Task Force on Mental Health (2010) recommends the screening of children and adolescents (beginning at 5 years) for behavioral and psychosocial problems at routine health maintenance visits as well as when psychosocial concerns arise. Major disparities have been identified in the provision of health and mental health services to children across the broad range of ethnic/racial groups and socioeconomic levels represented in the United States (Braveman & Barclay, 2009). For example, researchers have documented significant ethnic and racial disparities in service delivery for children with attention-deficit/hyperactivity disorder (ADHD) and other mental health conditions; children of minority status have been substantially underdiagnosed and undertreated (Flores & the Committee on Pediatric Research, 2010). Reducing health disparities requires comprehensive systemic efforts at multiple levels of the service delivery system (Braveman & Barclay, 2009), but one strategy to address this problem is to develop screening and assessment tools that are valid for use with children from diverse racial, ethnic, and socioeconomic populations. Parent-report instruments are commonly used to screen children for behavioral health concerns; yet, existing instruments are limited with regard to their inclusion of factors that are theoretically and clinically meaningful, their validity with diverse populations, and their feasibility for use in primary care. The Pediatric Symptom Checklist-17 (PSC-17) and the Strengths and Difficulties Questionnaire (SDQ) are the most well-researched and commonly used multidimensional scales for behavioral health screening in primary care. The PSC-17 was developed as a parent-report screening measure of externalizing, internalizing, and attention problems for children aged 4–17 years (Gardner et al., 1999). Studies to develop and evaluate the psychometric properties of this instrument have been conducted primarily with a non-Hispanic white population (Gardner, Lucas, Kolko, & Campo, 2007; Gardner, et al., 1999). A recent study provided evidence to support the validity of the PSC-17 with both white/Caucasian and black/African American samples (Stoppelbein, Greening, Moll, Jordan, & Suozzi, 2012). However, another study using a relatively large sample of predominantly black/African American low-income children (n = 320) served through urban primary care practices raised questions about the construct validity of the PSC-17 (Kostanecka et al., 2008). Specifically, many of the items, particularly on the externalizing and attention problems subscales, had significant loadings on more than one factor, and the three-factor model failed to meet statistical criteria for adequate model fit. In addition, the internalizing scale of the PSC-17 is limited in screening for anxiety, given that there is only one item that specifically refers to anxiety. Further, the PSC-17 uses one set of items across the preschool and adolescent years, even though there is considerable evidence of developmental variations in internalizing, externalizing, and attention problems across childhood (DuPaul, Power, Anastopoulos, & Reid, 1998; Luby et al., 2002; Weems & Costa, 2005). The SDQ, originally developed in Great Britain and studied extensively in Europe, is unique in that it has separate parent, teacher, and youth self-report versions, and it has scales for assessing both symptoms and impairments (Bourdon, Goodman, Rae, Simpson, & Koretz, 2005). The SDQ was designed to assess five dimensions (conduct problems, peer problems, emotional symptoms, inattention/hyperactivity, and prosocial behaviors). However, exploratory and confirmatory factor analyses of the SDQ conducted with a U.S. sample showed that a three-factor solution (internalizing, externalizing, and prosocial behavior) provided the best fit to the data (Dickey & Blumberg, 2004). A similar three-factor model was identified in a U.S. sample based on youth self-report (Ruchkin, Jones, Vermeiren, & Schwab-Stone, 2008). The failure to distill a distinguishable factor related to ADHD, a disorder commonly assessed by providers in pediatric practice, seems to be a noteworthy limitation of the SDQ, at least with a U.S. population. Also, although the SDQ includes separate forms for younger (4–10 years) and older (11–17 years) children, differences between these versions are relatively minor and may not reflect important developmental variations between these age-groups. Furthermore, the predictive validity of the SDQ has been questioned when only one informant is used, which raises concerns about its feasibility for use in a primary care setting (Goodman, Ford, Simmons, Gatward, & Meltzer, 2003). To address some of the limitations of existing screening measures, the Behavioral Health Checklist (BHCL) was developed. The BHCL is a parent-report measure designed to screen for common mental health conditions in the context of primary care. The measure was designed to: (1) provide valid and clinically meaningful screening of internalizing problems (anxiety and depression), externalizing problems (aggression and conduct problems), and ADHD (inattention and hyperactivity); (2) promote developmentally sensitive assessment across the age-range from 4 to 12 years; and (3) promote culturally sensitive assessment for the purposes of screening across urban and suburban populations, in particular white/Caucasian and black/African American children from low- and middle-income families. The first goal of the study was to evaluate whether the proposed three-factor model provided an adequate fit to the data for two age-groups, 4–7 years and 8–12 years. The second goal was to evaluate model fit across the following demographic parameters for each age-group: Boys versus girls, urban versus suburban, white/Caucasian versus black/African American, and lower versus higher socioeconomic status, as assessed by subsidized lunch status.