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More about Predicting the Unpredictable: Reflections on Psychopathology Screenings :

September 30, 2016

In a recently released paper in Pediatrics, Dr. Trude Sveen and colleagues from Trondheim, Norway bring us a timely new study, “Screening for Persistent Psychopathology in 4 year old Children.

In a recently released paper in Pediatrics, Dr. Trude Sveen and colleagues from Trondheim, Norway bring us a timely new study, “Screening for Persistent Psychopathology in 4 year old Children.” (10.1542/peds.2015-1648) It is known that the parent completed Strengths and Difficulties Questionnaire (SDQ) adequately screens for concurrent psychopathology in preschoolers, but these investigators asked if the SDQ can distinguish between transient and persistent psychopathology, and if so whether there is an optimal cut point score for “persistent cases.”

Certainly this is a highly relevant question for primary care providers. Interestingly the authors note that the SDQ accurately identifies more children with psychopathology than pediatric primary providers; however, without information about persistence, clinical impact is less clear. Please see an outstanding commentary on a closely related topic by Drs. Voigt and Accardo (Mission Impossible? Blaming Primary Care Providers for not Identify the Unidentifiable. Pediatr 2016; 138: pages??).  

Sveen and colleagues’ study benefits from a birth cohort approach, with 1038 children interviewed at age 4 years and 753 (72.5%) completing the 6 year old follow up interview. Results on the screening tool (SDQ) were compared to diagnostic interview with trained bachelor’s level interviewers blinded to SDQ results- in other words, exactly what we would hope for in a well done trial. I found the most instructive way to approach the results was to examine table 3, which gives the rates of diagnoses at ages 4 and 6 years, and the proportion of children who were “persistent cases” (diagnosed at both ages), “concurrent cases” (just diagnosed at age 4 years) and “prospective incident cases” (just diagnosed at age 6 years).  

The authors are completely transparent in reporting their results, which are limited in generalizability due to their homogenous Norwegian population with a relatively low rate of psychopathology.  At the author’s selected SDQ score cut point, most children who scored higher had persistent psychopathology and most scoring lower had only transient pathology.  But, and it’s a really big “but,” there was a relatively high rate of false positives, i.e. of children who had concurrent but not persistent psychopathology above the selected SDQ score cut point.  Please read the article for the quantitative details which are really interesting: a lot depends for example on the baseline rate of psychopathology in the screened community population.

The real dilemma here is for the practicing pediatrician.  You can certainly use this screening tool (SDQ) to help you identify children with psychopathology in order to guide parents to supports and resources. However, based on the information presented in this article, it is not clear that it would make sense to suggest to the parent that a cutoff  score demands more than the appropriate and usual follow up that meets the needs of the child.  In other words, the score should not be used to label or predict or repeat the screen at frequent intervals.  

What do you think? Would it help you to use a “tool,” however imperfect, to bring a parent back in for repeated assessments or to make sure the parent understands your concern about the child? Let us know by responding to this blog, posting a comment with the online article, or sharing your thoughts using our Facebook or Twitter sites. 

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