ARTICLE

Identification and Management of Psychosocial Problems Among Toddlers in Dutch Preventive Child Health Care
Sijmen A. Reijneveld, MD, PhD; Emily Brugman, MSc; Frank C. Verhulst, MD, PhD; S. Pauline Verloove-Vanhorick, MD, PhD

Objectives: To assess the degree to which preventive child health professionals (CHPs) identify and manage psychosocial problems among preschool children in the general population and to determine the association with parent-reported behavioral and emotional problems, sociodemographic factors, and mental health history of children. Design: The CHPs examined the child and interviewed the parents and child during their routine health assessments. The Child Behavior Checklist (CBCL) was completed by the parents. Setting: Sixteen child health care services across the Netherlands that routinely provided well-child care to nearly all preschool children. Patients: Of 2354 children aged 21 months to 4 years

Main Outcome Measures: Identification and management of psychosocial problems by CHPs. Results: In 9.4% of all children, CHPs identified psychosocial problems. Two in 5 of the CHP-identified children were referred for additional diagnosis and treatment. Identification of psychosocial problems and subsequent referral were much more likely in children with a clinical CBCL total problems score than in others (identification: 29% vs 7%; odds ratio [95% confidence interval], 5.40 [3.45-8.47]; referral: 15% vs 3%; odds ratio [95% confidence interval], 6.50 [3.69-11.46]). Conclusions: The CHPs frequently identify psychosocial problems in preschool children, although less than among school-aged children, but they miss many cases of parent-reported problems as measured by a clinical CBCL score. This general population study shows substantial room for improvement in the early identification of psychosocial problems.

who were eligible for a routine health assessment, 2229 (94.7%) participated.

Arch Pediatr Adolesc Med. 2004;158:811-817 2 and 3 years continued to have a psychiatric disorder 3.5 to 4 years later, using a variety of measures, including the Child Behavior Checklist (CBCL), to assess a psychiatric disorder. Similarly, in a retrospective study of antisocial behavior in adolescence, Moffitt and Caspi9 showed that adolescents with childhood-onset problems already had behavior problems at age 2 or 3 years, whereas Aguilar et al10 showed social-emotional indices to be similarly predictive. Mesman and Koot6 found parentreported internalizing and externalizing problems of preschool children to be predictive of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, counterparts 8 years later. Second, available reviews show that early interventions may be effective in preventing the continuation of psychosocial problems, especially antisocial behavior.11,12 In the Netherlands, preventive child health care offers an ideal opportunity for

From TNO (Netherlands Organisation of Applied Scientific Research) Prevention and Health, Leiden (Drs Reijneveld and Verloove-Vanhorick and Ms Brugman), Department of Health Sciences, Groningen University, Groningen (Dr Reijneveld), Erasmus University Rotterdam, Academic Hospital Rotterdam-Sophia, Rotterdam (Dr Verhulst), and Department of Paediatrics, Leiden University Medical Centre, Leiden (Dr Verloove-Vanhorick), the Netherlands.

as social-emotional and behavioral problems, are highly prevalent among children and adolescents and may severely interfere with everyday functioning of children and their families.1-5 Interest in the occurrence of these problems among toddlers has grown recently,2,4-7 whereas previous research mostly focused on school-aged children.1,8 As a consequence, relatively little is known of the occurrence of these problems among toddlers and the possibilities for early detection and subsequent treatment. Evidence in the general population is also lacking. Early detection and treatment may improve the prognosis of psychosocial problems among preschool children. First, psychosocial problems in preschool children may continue in later stages of life. Lavigne et al4 found that more than 50% of children with psychiatric disorders at age

SYCHOSOCIAL PROBLEMS, SUCH

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the early detection of psychosocial problems among preschool children, comparable to community pediatrics in the United States. In this system, child health professionals (CHPs) (ie, physicians and nurses) working in preventive child health care offer routine well-child care, including the early detection of psychosocial problems, to the entire Dutch population.13 Access is independent of insurance status, but the services do not provide treatment services, in contrast to the US system. We previously reported on the degree to which Dutch CHPs identified and managed psychosocial problems in children aged 4 to 16 years.1 One or more psychosocial problems were identified in 25% of all children, and 1 in 5 of the identified children were referred for further diagnosis and treatment. Results further showed that identification of psychosocial problems in children and subsequent referral were 6 times more likely in the 8% with serious parentreported problem behavior (measured by the CBCL). However, CHPs identified no psychosocial problems in 43% of these children and therefore undertook no action. We concluded that screening for psychosocial problems may be a promising option to reduce these problems among schoolaged children but that accuracy of the identification should be enhanced,1 for instance, by training of professionals or by the use of short screening questionnaires.14,15 The aim of the present study is to assess the degree to which CHPs identify and manage psychosocial problems among children aged 21 months to 4 years in the general population. We also assess which child factors are associated with the identification of psychosocial problems by CHPs and with their referral for further evaluation and treatment. Finally, we compare our results with a similar study of older children.1
METHODS Trained CHPs interviewed a national sample of parents on psychosocial problems among their toddlers from October 1, 1997, to June 30, 1998. SAMPLE The sample was obtained using a 2-step procedure. In the first step, a random sample of 16 of 65 child health services was drawn after stratification by region and degree of urbanization of their district. In the second step, each clinic provided a random sample of 75 children from their lists for 2 age groups: 2 years (2 months) and 3 years and 9 months (3 months), using random numbers. Of the 2354 eligible children, 2229 (94.7%) participated. The main reason for nonresponse was lack of interest in the objective of the study. The sample was representative for the entire Dutch population, except that infants living in big cities were relatively underrepresented due to the sampling procedure. PROCEDURE AND MEASURES The data were collected in a regular way as part of the preventive health assessments to which all Dutch children are invited regularly. The CBCL/2-3 was mailed to parents along with the regular invitation to the preventive health assessment. The CBCL was completed by the parents and returned to the researchers in a sealed envelope. After each childs physical examination, the CHP obtained sociodemographic and mental health history information following a standardized interview with the parents. After each assessment, the CHP responded yes or no to the following question, Does the child have a psy-

chosocial problem at this moment? The CHP then scored the type of identified problem(s) on a precoded list. Children who only had risk indicators for the development of psychosocial problems, such as parents with psychiatric problems or other family problems, had to be coded as no. If a problem was identified, the CHP was asked to rate the severity of the problem (mild, moderate, or severe) and to indicate how the problem was managed (precoded question). The design of the study was approved by the local medical ethical committee. It was similar to simultaneously performed studies on younger (1-6 months)16,17 and older (4-16 years) children.1,18 The CBCL/2-3 was used to assess the parents report on the childs behavioral and emotional problems during the preceding 6 months.19 The good reliability and validity of the CBCL/ 2-3 established by Achenbach19 were confirmed for the Dutch translation.20,21 The CBCL/2-3 consists of 99 problem items and 3 additional items regarding handicaps and parental worries. Seven syndrome scales, 2 broad-band groups of syndromes designated internalizing and externalizing, and a total problems score were computed. Internalizing consists of the withdrawn/ depressed and anxious syndrome scales, externalizing consists of the oppositional, aggressive behavior, and overactive syndrome scales, and sleep problems and somatic problems constitute separate syndrome scales. The overactive syndrome scale is specific for the Dutch version, whereas the further structure of the instrument is similar to the US version.21 Cases were subsequently allocated to a normal range or a clinical range of the scoring distributions for each separate scale based on the Dutch normative sample (H. M. Koot, PhD, written communication, April 28, 1999). Cutoffs were set at the 97th percentile for the 7 syndrome scales and at the 90th percentile for the total problems and internalizing and externalizing scales. The sociodemographic variables assessed were sex, age, ethnicity, family composition, number of siblings living in the family at the time of study, educational level and employment status of the parent(s), degree of urbanization, duration of pregnancy, type of delivery, postdelivery hospitalization of the child, parity, and day care. Ethnicity was based on the native country of the child and both biological parents. At least 2 of them had to be born outside the Netherlands to qualify as nonDutch. Parental educational level was used as a measure of socioeconomic status and based on the highest degree completed by the father or mother. Degree of urbanization was assessed using the postal code of the address of residence.22 Data on mental health history expressed whether the child was currently being treated (point prevalence) or had been treated (lifetime prevalence) for psychosocial problems. Response options included mental health professionals (eg, psychiatrist, psychologist), medical professionals (eg, general practitioner, pediatrician), and other professionals (eg, specialized family help, parenting support). In addition, life events in the previous year (such as hospitalization, death of family member, unemployment, divorce) were assessed in a standardized way. ANALYSIS First, we examined the prevalence of psychosocial problems as identified by CHPs. Second, we analyzed the management strategies used by CHPs and their relation to the severity of the problems. We used 2 tests to determine the statistical significance of differences between distributions of categorical data. Third, we assessed which child factors (CBCL problem scales, sociodemographic variables, and [mental] health history variables) were related to the identification of psychosocial problems by CHPs (no or yes), using univariate and multivariate logistic regression analyses. We repeated these analyses regarding a referral for psychosocial problems by CHPs (no or yes). All independent child variables were dichotomized.

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Table 1. Management Strategies of CHPs in Case of Psychosocial Problems According to the Severity of the Problems as Rated by CHPs*
Severity, % of Children Strategy No action Advice or reassurance Follow-up with parents and child Consultation with others Referral to others Any action that implies follow-up (follow-up, consultation, and/or referral) Children, Total No. (%) 31 (16) 144 (72) 47 (24) 28 (14) 81 (41) 102 (51) Mild (n = 101) 19 79 18 9 26 36 Moderate (n = 79) 13 65 22 13 49 62 Severe (n = 19) 11 68 63 47 84 84 P Value .43 .09 .001 .001 .001 .001

Abbreviation: CHPs, child health professionals. *Nontreated weighted sample in which CHPs identified psychosocial problems (n = 200). More than one management strategy per child could be indicated. Data on severity are missing for 1 child. P value ( 2 test) for differences by severity in the occurrence of each option.

The regression analyses were performed using multilevel techniques because of the hierarchical nature of the data: characteristics of a CHP may have an impact on the assessments of all the children who are seen by the CHP. Multilevel models account for this clustering of individual data by the CHP (n=108).23,24 Prevalence estimates presented in the tables and text are weighted by region and age to adjust for differences between the study population and the Dutch population. Test statistics, odds ratios (ORs), and 95% confidence intervals (CIs) were calculated on the basis of the unweighted data. RESULTS

PROBLEM IDENTIFICATION In 200 (9.4%) of all 2229 children, the CHP identified 1 or more psychosocial problems. The severity of the problems was rated as mild in 50.8% of these cases, moderate in 39.7%, and severe in 9.5%. At the time of the study, 1.0% of all children were being treated for psychosocial problems by a mental health professional. This group was excluded from all further analyses and 1 child with missing data on CHP-identified problems (the remaining number of nontreated children was 2205). MANAGEMENT STRATEGIES The CHPs undertook actions in 84% of the nontreated children with identified psychosocial problems. Various management strategies were used: advice or reassurance (72.4%); consultation with day care, colleagues, or official authorities (24.1%); follow-up (23.6%); and referral to another professional (40.7%). Management strategies varied according to the severity of the problems as rated by the CHP (Table 1). Follow-up, consultation, and referral were more frequent in those children whose psychosocial problems were rated moderate or severe. CHILD FACTORS RELATED TO PROBLEM IDENTIFICATION AND REFERRAL
Table 2 presents the number of nontreated children with a CBCL total problems score in the normal and clinical

range who were identified by CHPs as having psychosocial problems and the management strategies used. Of the nontreated children, 6.1% had a CBCL total problems score in the clinical range (6.4% of all children). The CHPs identified psychosocial problems in 29.4% of the children with a CBCL total problems score in the clinical range (cutoff at 90th percentile). This percentage was 43.6 for those scoring above the 98th percentile of the CBCL total problems score and 47.6 for the children scoring above the 99th percentile. The CHPs identified psychosocial problems in 6.8% of the children with a CBCL total problems score in the normal range. These problems were rated as mild in 60.8% of the cases, moderate in 33.4%, and severe in 5.9%; the CHP rating of children scoring in the clinical range of the CBCL total problems score was 28.0%, 45.8%, and 26.2%, respectively ( 2 =19.03, P .001). No actions were taken in 75.4% of all children with a CBCL total problems score in the clinical range; in 93.8% of these cases this was due to the fact that CHPs had identified no psychosocial problems. Referral to another professional was almost 6 times more likely in children with a CBCL total problems score in the clinical range (15.1%) than in those scoring in the normal range (2.6%). Table 3 presents the association of CBCL problem scales with the identification of and referral for psychosocial problems by CHPs. Identification and referral were 5.4 (95% CI, 3.5-8.5) and 6.5 (95% CI, 3.7-11.5) times more likely in case of an elevated CBCL total problems score, respectively. Looking at CBCL broad-band scales, the ORs were much higher for elevated externalizing scores than for elevated internalizing scores, however, and this was reflected by the associations for the syndrome scales, with ORs being highest for the oppositional and overactive syndromes. Concerning the sociodemographic variables, Table 4 shows that CHPs identified psychosocial problems relatively frequently in some groups: older children, children of single parents, and children with parents of low educational level. Referral depends on other characteristics, however, being more likely among nonDutch children and children of parents of low educational level. Factors related to pregnancy and delivery had
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Table 2. Identification of Psychosocial Problems by CHPs and Management Strategies Used in Relation to the CBCL Total Problems Score*
CBCL Total Problems Score, No. (%) of Children Variable Identification of psychosocial problems Management strategies No action Advice or reassurance Follow-up with parents and child Consultation with others Referral to others Any action that implies follow-up (follow-up, consultation with others, and/or referral) Children, Total No. (%) 169 (8) 1919 (93) 121 (6) 44 (2) 23 (1) 69 (3) 87 (4) Normal (n = 1937) 132 (7) 1824 (94) 96 (5) 29 (2) 12 (1) 50 (3) 63 (3) Clinical (n = 126) 37 (29) 95 (75) 25 (20) 15 (12) 11 (9) 19 (15) 24 (19) P Value .001 .001 .001 .001 .001 .001 .001

Abbreviations: CBCL, Child Behavior Checklist; CHP, child health professional. *Nontreated weighted sample (n = 2063). Of the initial sample of 2229 children, 23 were excluded because they were receiving treatment, 1 because problems were not registered, and 142 because of incomplete or missing CBCL data. Because of these exclusions, numbers for the various actions are somewhat lower than in Table 1. 2 Test. More than one management strategy per child could be indicated.

Table 3. Results Derived From Multilevel Univariate Logistic Regression Analyses of CBCL Problem Scales Increasing the Probability of Identification of and Referral for Psychosocial Problems by CHPs*
Clinical Range CBCL Problems Scales Total problems Internalizing Externalizing Oppositional Withdrawn/ depressed Aggressive behavior Anxious Overactive Sleep problems Somatic complaints OR (95% CI) Children, No. (%) 129 (6.3) 136 (6.6) 114 (5.5) 27 (1.3) 14 (0.7) 28 (1.4) 19 (0.9) 13 (0.6) 26 (1.3) 26 (1.3) Identification 5.40 (3.45-8.47) 2.97 (1.82-4.83) 7.65 (4.90-11.95) 19.77 (8.56-45.65) 6.40 (2.02-20.29) 3.04 (1.16-8.00) 3.88 (1.31-11.52) 10.25 (3.45-30.47) 7.04 (3.02-16.40) 3.83 (1.52-9.68) Referral 6.50 (3.69-11.46) 2.53 (1.26-5.07) 8.86 (5.08-15.44) 17.99 (8.12-39.88) 4.90 (1.06-22.58) 2.18 (0.50-9.42) 3.44 (0.77-15.33) 10.06 (2.71-37.32) 5.25 (1.75-15.79) 1.11 (0.15-8.31)

the higher-order externalizing and internalizing scales, and to the total problems scale, 3 models were tested for both dependent variables. All models contained the sociodemographic and mental health history variables. Further, the first model contained the total problems scale, the second one contained the broad-band scales, and the third one the CBCL syndrome scales, as far as they univariately had a statistically significant relation with each outcome. These results show that the associations of CBCL and mental history variables with both identification and referral were much stronger than those of sociodemographic variables. Furthermore, the set of variables that predicts referral was much smaller than the one that predicts identification. Finally, day care was associated with less identification after adjustment for the other variables, whereas it was not in the univariate model. Additional adjustment for all other variables that had been included in Tables 3 and 4 yielded similar results (not shown).
COMMENT

Abbreviations: CBCL, Child Behavior Checklist; CHPs, child health professionals; CI, confidence interval; OR, odds ratio. *Nontreated sample (n = 2063). Of the initial sample of 2229 children, 23 were excluded because they were receiving treatment, 1 because problems were not registered, and 142 because of incomplete or missing CBCL data. The number of children with a clinical total problems score slightly differs from Table 2 because of the weighting in that table.

no relation with either identification or referral. Finally, parent-reported past treatments for psychosocial problems were significantly related to both the identification of and referral for psychosocial problems. Table 5 provides the results of multiple logistic regression analyses. It lists those variables that were significantly related to the identification of psychosocial problems by CHPs (in the second column) and to referral for these problems (in the third column) after adjustment for the effect of all other variables. Due to the hierarchical structure of the CBCL scales in which problem items can contribute at the same time to syndrome scales, to

Physicians and nurses working in preventive child health care identified psychosocial problems in 9.4% of the general population of children aged 21 months to 4 years and mostly rated these cases as mild or moderate. The CHPs undertook actions in most of the identified cases of psychosocial problems, mainly by giving advice to parents but relatively frequently also by referring them. Two in 5 of the CHP-identified children were referred for further diagnosis and treatment. Identification of psychosocial problems and subsequent referral were much more likely (5.4 and 6.5 times, respectively) in children with CBCL total problems scores in the clinical range than in other ones. However, CHPs identified no psychosocial problems in most children (71%) with such a score in the clinical range. Methodologic factors may partially explain why CHPs do not identify all children with parent-reported problems on the CBCL and vice versa, even though the
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Table 4. Results Derived From Multilevel Univariate Logistic Regression Analyses of Sociodemographic and (Mental) Health History Variables Increasing the Probability of Identification of and Referral for Psychosocial Problems by CHPs*
OR (95% CI) Variable Sociodemographic Female 3.5 to 4 y Non-Dutch One-parent family No siblings Medium or high parental educational level Parents employed 16 h/wk Very highly urbanized Pregnancy duration 37 wk Artificial delivery (vacuum, section) Birth weight 2500 g Hospitalization after birth Second and older child Day care (Mental) health history Past psychological treatment for psychosocial problems Past medical treatment for psychosocial problems Past other treatment for psychosocial problems Subjected to life event (past year) Parent report of physical illness or handicap Past psychological treatment for psychosocial problems Children, No. (%) 1047 (50.8) 1070 (51.9) 71 (3.4) 72 (3.5) 502 (24.3) 1544 (74.8) 89 (4.3) 489 (23.7) 100 (4.9) 452 (22.6) 97 (4.7) 297 (14.5) 1537 (74.7) 1389 (67.5) 33 (1.6) 110 (5.3) 24 (1.2) 1007 (48.8) 148 (7.2) 33 (1.6) Identification 0.82 (0.60-1.14) 1.45 (1.05-2.02) 1.50 (0.70-3.20) 3.79 (2.08-6.92) 1.02 (0.70-1.48) 0.45 (0.32-0.64) 1.67 (0.86-3.25) 1.27 (0.82-1.96) 1.19 (0.59-2.43) 0.94 (0.63-1.40) 1.67 (0.88-3.16) 1.09 (0.69-1.71) 0.99 (0.69-1.44) 0.86 (0.61-1.21) 17.98 (8.78-36.82) 11.80 (7.47-18.63) 13.25 (5.84-30.03) 1.19 (0.88-1.62) 1.20 (0.69-2.09) 17.98 (8.78-36.82) Referral 0.74 (0.45-1.20) 1.15 (0.71-1.86) 2.85 (1.18-6.86) 2.22 (0.86-5.73) 0.94 (0.53-1.66) 0.40 (0.24-0.65) 2.66 (1.18-6.04) 1.39 (0.81-2.38) 0.90 (0.28-2.92) 0.82 (0.45-1.52) 0.93 (0.29-3.03) 0.78 (0.37-1.66) 1.05 (0.60-1.84) 0.90 (0.54-1.49) 17.00 (7.88-36.69) 12.76 (7.46-21.83) 16.21 (6.68-39.33) 1.55 (0.95-2.54) 0.80 (0.29-2.25) 17.00 (7.88-36.69)

Abbreviations: CHPs, child health professionals; CI, confidence interval; OR, odds ratio. *Nontreated sample (n = 2063). Of the initial sample of 2229 children, 23 were excluded because they were receiving treatment, 1 because problems were not registered, and 142 because of incomplete or missing CBCL data. Reference categories are male; 21 to 27 months; Dutch; 2-parent family; 1 or more siblings; low parental educational level; at least 1 parent working more than 16 hours a week; not or mildly urbanized; 37 weeks and more; normal delivery; 2500 g and over; no hospitalization; first child; and no day care, respectively. Derived from 1-level model.

CBCL is one of the best validated and most widely used parent-report questionnaires to assess psychosocial problems of children. First, CHPs identify a broad range of psychosocial problems, from rather minor behavioral problems to major psychiatric morbidity, whereas high CBCL scores typically occur among children who have been referred to psychiatric services. We thus expect CHPs to identify on the whole less severe problems and at the same time a lot more problems. Interestingly, the latter only partially applies, since CHPs identified problems in 9.4% of all children, whereas 6.4% of all children had a clinical CBCL total problems score. Second, the CBCL/ 2-3 is an imperfect gold standard. The sensitivity and specificity of the Dutch version at the cutoff for the borderline clinical range are 63% and 84%, respectively, using referral to mental health care as the criterion (OR, 8.720; for the US version, the OR was 9.1).19 Assuming a true prevalence of problems of 10%, this implies that two thirds of the CBCL cases produced false-positive cases for which the CHP was right in not identifying problems. Third, the CBCL only provides parent information, whereas CHP identification is also based on the child and on information from colleagues observing the same child. Disagreement between various informants on behavioral and emotional problems has been extensively documented. The mean Pearson correlation, for instance, between problem scales derived from different informants is only 0.22.25 This will again lead to less concordance between CBCL and CHP identification.

Other methodologic factors are unlikely to have biased our results significantly. The response in our study was very high (94.7%), and it concerned a representative sample of the Dutch population. Only children living in highly urbanized areas, which included many nonDutch children, were underrepresented26 because of the sampling procedure. This may have led to some underestimation of the prevalence of CHP-identified problems, because they identified problems somewhat more frequently among these groups, although differences were not statistically significant. On the other hand, parents filled out the CBCL in advance and were thus forced to think about their childs problems, which may have lead to higher rates of reported problems. Finally, the prevalence of clinical CBCL scores in our sample was somewhat lower than in the Dutch normative sample.20 An explanation may be that the Dutch normative study concerned a relatively small sample (n=420) from one province, including a metropolitan area.20 Our results show that both CHP identification of psychosocial problems and subsequent referral are strongly related to parent-reported problems on the CBCL and to previous treatment for psychosocial problems but less to sociodemographic background. Regarding the CBCL, especially troublesome behavioral problems that bring the child in conflict with the environment are highly predictive, as is shown by the high ORs for clinical scores on externalizing problems (7.65) and for contributing syndrome scales such as oppositional and overactive (19.8
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Table 5. Results Derived From Multilevel Multiple Logistic Regression Analyses of Significant Child Factors Increasing the Probability of Identification of and Referral for Psychosocial Problems by CHPs*
OR (95% CI) Child Factors Clinical range CBCL problem scales Total problems Externalizing Oppositional Overactive Sleep problems Sociodemographic variables 3.5 to 4 years One-parent family Medium or high parental educational level Day care (Mental) health history variables Past psychological treatment for psychosocial problems Past medical treatment for psychosocial problems Identification Referral

What This Study Adds The prevalence of psychosocial problems is high among preschool- and school-aged children. Early detection and treatment improve the prognosis of these problems. Preventive child health care offers an ideal opportunity for the early detection and subsequent treatment of psychosocial problems. However, evidence on this early detection among preschool children in the general population is lacking. This study shows that psychosocial problems among preschool children are identified frequently by preventive child health care but that many cases of parentreported problems are missed. Substantial effort should be invested in the improvement of this early detection.

3.43 (2.04-5.75) 4.88 (2.93-8.14) 9.23 (3.48-24.49) 7.16 (1.62-31.54) 4.85 (1.70-13.83) 1.68 (1.09-2.60) 3.20 (1.63-6.27) 0.54 (0.37-0.80) 0.54 (0.34-0.85) 8.78 (3.72-20.76) 8.58 (5.16-14.27)

3.74 (1.97-7.13) 4.93 (2.62-9.30) 3.88 (1.31-11.51) ... ... ... ... 0.44 (0.26-0.75) ... 4.97 (1.93-12.83) 8.36 (4.53-15.42)

Abbreviations: CBCL, Child Behavior Checklist; CHPs, child health professionals; CI, confidence interval; OR, crude odds ratio. *Nontreated sample (n = 2063). Of the initial sample of 2229 children, 23 were excluded because they were receiving treatment, 1 because problems were not registered, and 142 because of incomplete or missing CBCL data. Only those child factors that contribute to the prediction of identification and/or of referral are shown. Child factors that contribute to neither of these 2 are not shown. Results regarding CBCL scales refer to 3 different models that all comprise the same sociodemographic variables and mental health history variables but different sets of CBCL variables: one set contains only the total problems scale, one only the externalizing scale, and one only the 3 CBCL syndrome scales. Because the results regarding sociodemographic variables and (mental) health history variables were almost identical, only the ORs of these for the first model (ie, with adjustment for the total problems scale) are listed in this table. For reference categories, see Table 4.

and 10.2, respectively). A clinical score on the internalizing scale had no independent association with either identification or referral, and the same holds true for the syndrome scales withdrawn/depressed and anxious; these problems reflect inner conflicts of the child. Regarding sociodemographic background, relatively few characteristics contribute to identification and even less to referral, and characteristics of pregnancy and delivery contribute to neither of these. Thus, CHPs mostly base their identification of psychosocial problems on the mental health characteristics of the child and not on the childs background, and this holds even stronger for the decision to refer a child. Regarding this, the only background characteristic that predicts referral in the multivariate model, parental educational level, may also be interpreted as a proxy for parental skills to solve existing problems, but further research on this is needed. The results of the present study show some interesting differences compared with our earlier study that was designed to study identification and management of problems among school-aged children (ages 4-16 years) in an identical way.1 First, rates of CHP identification of problems were much higher in the school-aged group (25% vs 9% in the preschool group). Next, the rates of referral of

those identified and not yet under treatment were higher in the present study (41% vs 21%). True differences in the prevalence of problems between these age groups may account for these differences or a reluctance of CHPs to define mild behavioral problems among toddlers as psychosocial. Regarding the first explanation, it is interesting that in the present study CHPs identify relatively more problems among the oldest group (ages 3.5-4 years), whereas in the previous study this applies to those aged 4 to 11 years (compared with 12-16 years). This indicates a steady increase in problems until the end of primary school and a decrease afterward. A recent study by Bongers et al27 indeed shows mean CBCL total problems and externalizing scores to decrease from the age of 4 years until the age of 18 years, with the decreases being somewhat steeper for boys. Regarding preschool children, no data are available. Second, among toddlers a clinical score on CBCL internalizing problems has a relatively small and not independent association with both CHP identification and referral, whereas among school-aged children the ORs for internalizing problems are similar to those for externalizing problems. For instance, among the latter the adjusted ORs (95% CIs) for identification are 2.49 (1.903.28) and 1.93 (1.48-2.53), respectively. An explanation may be that behavioral problems, covered by the externalizing CBCL scale, are really the major part of psychosocial problems among young children. An alternative explanation may be that in young children behavioral problems can be observed much more easily than emotional problems because of their limited verbal capacities. Probably both factors contribute. Third, among school-aged children, the independent association of sociodemographic background characteristics with identification and referral was even smaller, with only age and urbanization being associated with identification and none with referral. Differences in sample size and thus in power to detect associations could also account for these differences if the present study had concerned more children, but in fact the sample size of the present study was approximately half the size of the study on school-aged children. Moreover, when only examining the strength of associations and not their statistical significance, similar results were obtained. Above all, it should be realized that in both age groups variables related to mental health and previous treatment dominate with regard to
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both CHP identification and referral, and this seems to be reinforced with increasing ages. This information can in all likelihood be obtained more easily in older children. As far as we know our study is one of the first to examine CHP identification of psychosocial problems and subsequent management among preschool children and the first based on a population sample that also comprises children not seeking curative care. In 2 studies conducted in Monroe County, New York, in the late 1970s, Goldberg et al28,29 found that 3.3% to 3.5% of children aged 1 to 4 years who visited a pediatrician had mental health problems. Starfield et al30 found that 4.5% to 15% of children aged 1 to 4 years received a psychosocial diagnosis. Finally, Lavigne et al5 found a rate of pediatricianidentified emotional and behavioral problems similar to ours (9.3%) among children aged 2 to 3 years who visited a pediatrician from the US Pediatric Practice Research Group for any reason. In that study, sensitivity and specificity of pediatrician identification were 20.5% and 92.7%, respectively, using an assessment by a child psychologist as the gold standard. Because our study comprised all children in a general population, our prevalence rates are difficult to compare with these. However, our results regarding accuracy of identification confirm those of Lavigne et al.5 Thus, substantial room exists for improvement in the early detection of psychosocial problems among preschool children. This may, for instance, be reached by the use of short symptom checklists that parents fill out before the assessment31; training of professionals in the assessment of psychosocial problems, including the use of other informants such as day care providers and a separate developmental assessment to sort out developmental delay as a cause of behavioral problems; and reserving more time per visit. If a child has been referred, another problem may be engaging the child effectively in mental health services, especially if waiting lists are long.32 This makes it even more necessary to refer the children and families who are most in need. Our results need confirmation in other communitybased studies of preschool children, including the use of other criteria as a gold standard for child mental health, in addition to the CBCL. A next step should be the evaluation of various methods to improve early detection and effective early treatment and referral. Accepted for publication March 12, 2004. This study was financially supported by the Dutch Ministry of Health, Welfare, and Sports, The Hague, the Netherlands; the Praeventiefonds (grant 28-2628-1), The Hague; and Zorg Onderzoek Nederland (grant 101004-12), The Hague. We thank the personnel of the 16 Dutch child health care services who participated in this study. Correspondence: Sijmen A. Reijneveld, MD, PhD, Department of Health Sciences, Groningen University, PO Box 196, 9700 AD Groningen, The Netherlands (S.A.Reijneveld @med.rug.nl).
REFERENCES
1. Brugman E, Reijneveld SA, Verhulst FC. Identification and management of psychosocial problems by preventive child health care. Arch Pediatr Adolesc Med. 2001;155:462-469.

2. Briggs-Gowan MJ, Carter AS, Skuban EM, Horwitz SM. Prevalence of socialemotional and behavioral problems in a community sample of 1- and 2-year-old children. J Am Acad Child Adolesc Psychiatry. 2001;40:811-819. 3. Verhulst FC, van der Ende J. Factors associated with child mental health service use in the community. J Am Acad Child Adolesc Psychiatry. 1997;36:901-909. 4. Lavigne JV, Arend R, Rosenbaum D, Binns HJ, Christoffel KK, Gibbons RD. Psychiatric disorders with onset in the preschool years, I: stability of diagnoses. J Am Acad Child Adolesc Psychiatry. 1998;37:1246-1254. 5. Lavigne JV, Binns HJ, Christoffel KK, et al, Pediatric Practice Research Group. Behavioral and emotional problems among preschool children in pediatric primary care: prevalence and pediatricians recognition. Pediatrics. 1993;91:649-655. 6. Mesman J, Koot HM. Early preschool predictors of preadolescent internalizing and externalizing DSM-IV diagnoses. J Am Acad Child Adolesc Psychiatry. 2001; 40:1029-1036. 7. Mesman J, Bongers IL, Koot HM. Preschool developmental pathways to preadolescent internalizing and externalizing problems. J Child Psychol Psychiatry. 2001;42:679-689. 8. Leaf PJ, Alegria M, Cohen P, et al. Mental health service use in the community and schools: results from the four-community MECA Study. J Am Acad Child Adolesc Psychiatry. 1996;35:889-897. 9. Moffitt TE, Caspi A. Childhood predictors differentiate life-course persistent and adolescence-limited antisocial pathways among males and females. Dev Psychopathol. 2001;13:355-375. 10. Aguilar B, Sroufe LA, Egeland B, Carlson E. Distinguishing the early-onset/ persistent and adolescence-onset antisocial behavior types: from birth to 16 years. Dev Psychopathol. 2000;12:109-132. 11. Durlak JA, Wells AM. Evaluation of indicated preventive intervention (secondary prevention) mental health programs for children and adolescents. Am J Community Psychol. 1998;26:775-802. 12. Webster-Stratton C, Taylor T. Nipping early risk factors in the bud: preventing substance abuse, delinquency, and violence in adolescence through interventions targeted at young children (0-8 years). Prev Sci. 2001;2:165-192. 13. Minister of Public Health. Basistakenpakket Jeugdgezondheidszorg [Listing of Basic Tasks for Preventive Child Health Care]. The Hague, the Netherlands: Ministry of Public Health & Sports; 2001. 14. Reijneveld SA, Vogels AG, Brugman E, Van Ede J, Verhulst FC, VerlooveVanhorick SP. Early detection of psychosocial problems in adolescents: how useful is the Dutch short indicative questionnaire (KIVPA)? Eur J Public Health. 2003; 13:152-159. 15. Vogels T, Reijneveld SA, Brugman E, den Hollander-Gijsman ME, Verhulst FC, Verloove-Vanhorick SP. Detecting psychosocial problems among 5-6 year-old children in Preventive Child Health Care: the validity of a short questionnaire used in an assessment procedure for detecting psychosocial problems among children. Eur J Public Health. 2003;13:353-360. 16. Reijneveld SA, Brugman E, Hirasing RA. Excessive infant crying: the impact of varying definitions. Pediatrics. 2001;108:893-897. 17. Reijneveld SA, Brugman E, Hirasing RA. Excessive infant crying: definitions determine risk groups. Arch Dis Child. 2002;87:43-44. 18. Harland P, Reijneveld SA, Brugman E, Verhulst FC. Family factors and life events as risk factors for behavioural and emotional problems in children. Eur Child Adolesc Psychiatry. 2002;11:176-184. 19. Achenbach TM. Manual for the Child Behavior Checklist/2-3 and 1992 Profile. Burlington: University of Vermont; 1992. 20. Koot HM. Problem Behavior in Dutch Preschoolers [PhD thesis]. Rotterdam, the Netherlands: Erasmus University; 1993. 21. Koot HM, Van Den Oord EJ, Verhulst FC, Boomsma DI. Behavioral and emotional problems in young preschoolers: cross-cultural testing of the validity of the Child Behavior Checklist/2-3. J Abnorm Child Psychol. 1997;25:183-196. 22. Statistics Netherlands. Kerncijfers Vierpositie Postcodegebieden, 1995 [Key Figures on Four Digit Postcode-Areas, 1995]. Voorburg/Heerlen: Statistics Netherlands; 1997. 23. Goldstein H. Multilevel Statistical Models. London, England: Edward Arnold; 1995. 24. Goldstein H, Rasbash J, Plewis I, et al. A Users Guide to MLwiN. London, England: University of London, Multilevel Models Project; 1998. 25. Achenbach TM, McConaughy SH, Howell CT. Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity. Psychol Bull. 1987;101:213-232. 26. Statistics Netherlands. Second generation foreigners (narrow definition) by country of birth of the mother, age, sex, and marital status, 1 January 1998. CBS Maandstatistiek van de Bevolking. 1998;(11):31. 27. Bongers IL, Koot HM, van der EJ, Verhulst FC. The normative development of child and adolescent problem behavior. J Abnorm Psychol. 2003;112:179-192. 28. Goldberg ID, Regier DA, McInerny TK, Pless IB, Roghmann KJ. The role of the pediatrician in the delivery of mental health services to children. Pediatrics. 1979; 63:898-909. 29. Goldberg ID, Roghmann KJ, McInerny TK, Burke JDJ. Mental health problems among children seen in pediatric practice: prevalence and management. Pediatrics. 1984;73:278-293. 30. Starfield B, Gross E, Wood M, et al. Psychosocial and psychosomatic diagnoses in primary care of children. Pediatrics. 1980;66:159-167. 31. Carter AS, Briggs-Gowan MJ, Jones SM, Little TD. The Infant-Toddler Social and Emotional Assessment (ITSEA): factor structure, reliability, and validity. J Abnorm Child Psychol. 2003;31:495-514. 32. Rushton J, Bruckman D, Kelleher K. Primary care referral of children with psychosocial problems. Arch Pediatr Adolesc Med. 2002;156:592-598.

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