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Pediatrician Identification of Child Behavior Problems:The Roles of Parenting Factors and Cross-Practice Differences
Robert M. Dempster • Beth G. Wildman •
Diane Langkamp • John C. Duby
� Springer Science+Business Media, LLC 2011
Abstract While most primary care pediatricians acknowl-
edge the importance of identifying child behavior
problems, fewer than 2% of children with a diagnosable
psychological disorder are referred for mental health care
in any given year. The present study examined the potential
role of parental characteristics (parental affect, parenting
style, and parenting self-efficacy) in pediatrician identifi-
cation of child behavior problems, and determined whether
these relationships differed across practices. Parents of 831
children between 2 and 16 years completed questionnaires
regarding demographic information, their child’s behavior,
their affect, their parenting style, and their parenting self-
efficacy. Pediatricians completed a brief questionnaire
following visits in four community-based primary care
practices in the Midwest. Logistic regressions controlling
for child behavior and demographic predictors of pedia-
trician identification found that an authoritarian parenting
style, in which parents yell or strongly negatively react to
problem behavior, was negatively associated with likeli-
hood of identification in the overall sample. However, the
variables that were predictive of pediatrician identifica-
tion differed depending on the specific practice. Parental
characteristics can aid in understanding which children are
likely to be identified by their pediatrician as having
behavioral problems. The finding that practices differed on
which variables were associated with pediatrician identifi-
cation suggests the need to potentially individualize inter-
ventions to certain physicians and practices to improve
identification of child behavior problems in primary care.
Keywords Primary care � Identification of child
behavioral problems � Parenting
Introduction
Externalizing child behavior problems, such as opposi-
tional defiant disorder, conduct disorder, and attention
deficit hyperactivity disorder, compose the majority of
psychological disorders in children and adolescents, with
approximately 12–13% of children exhibiting these types
of disorders (Briggs-Gowan, Horwitz, Schwab-Stone,
Leventhal, & Leaf, 2000; Carter et al., 2010). When
untreated, child behavior problems tend to persist over time
and may lead to long term negative outcomes, such as
impaired school and social functioning, problems with the
law, and antisocial personality disorder (Clarizio, 1997;
Coid, 2003). Although effective treatments are available
for child behavior problems (Brestan & Eyberg, 1998;
Kazdin & Weisz, 2003), only 2% of children with any
diagnosable behavioral or emotional problem are seen in a
given year by a mental health professional (Costello, 1986;
Pottick et al., 2007). Over time, these problems become
more resistant to treatment (Webster-Stratton & Reid,
2003) and lead to rejection by peers, teachers, and even
parents (Loeber & Farrington, 2000).
R. M. Dempster � B. G. Wildman
Department of Psychology, Kent State University,
Kent, OH, USA
R. M. Dempster (&)
794, Alexandria Colony Ct, Columbus, OH 43215, USA
e-mail: [email protected]
D. Langkamp � J. C. Duby
Department of Developmental and Behavioral Pediatrics,
Akron Children’s Hospital, Akron, OH, USA
123
J Clin Psychol Med Settings
DOI 10.1007/s10880-011-9268-x
Primary care pediatricians (PCPs) are in an excellent
position to identify these children since PCPs are typically
the first professional to have on-going contact with the
child, most children are seen by a PCP at least once in a
given year, and PCPs can often facilitate management of
mental health concerns. Although PCPs generally have
positive views towards treating child behavior problems
(Steele, Lochrie, & Roberts, 2010), less than 25% of the
children who present to PCPs with behavior problems are
identified or treated by their PCP (U.S. Department of
Health and Human Services, 1999). The present study
examined the relationship between PCP identification of
child behavior problems and parent factors that are likely to
be available to PCPs, such as parental affect, sense of
efficacy with their parenting, and parenting practices.
The process that actually leads to PCP identification of
child behavior problems (PID) appears to be complex and
related to parent, child, and PCP factors. Even when par-
ents report disclosing concerns about their child’s mental
health to their child’s PCP, PCPs do not necessarily address
these concerns (Wildman, Stancin, Golden, & Yerkey,
2004). There is also little current empirical research related
to the processes that determine which children are identi-
fied by PCPs and differences among PCPs in identification
rates. The limited research available has shown that PCP
and practice factors such as greater training, greater per-
ceived treatment efficacy, and fewer time constraints are all
positively associated with PID. Despite the availability of
effective interventions to improve PID, such as paper and
pencil (Pagano, Cassidy, Little, Murphy, & Jellinek, 2000)
or computerized (Chisolm, Gardner, Julian, & Kelleher,
2007) screening instruments, as well as interventions
improving communication between parents and PCPs
(Wissow et al., 2011), PID occurs at an alarmingly low
rate.
The finding that child symptoms alone do not ade-
quately predict PID (Briggs-Gowan et al., 2000) suggests
the importance of understanding the relationship of factors
outside of the child to PID. Since parents are the primary
source of information about a child’s behavior during brief
primary care visits (Costello & Edelbrock, 1985), parental
beliefs, attitudes, and behavior likely play a role in PID
(Brown & Wissow, 2008). For example, parental disclo-
sure of concern regarding their child’s behavior is a strong
predictor of PID (Brown & Wissow, 2008; Dulcan et al.,
1990). Previous research has found a relationship between
parental affect and PID, such that parental negative affect
and/or psychopathology is associated with higher rates of
PID (Dulcan et al., 1990; Wildman et al., 2004). PCPs are
likely to attend to aspects of the parent that are easily
assessed or readily apparent during a visit, such as
parental affect, sense of parenting efficacy, and parenting
practices.
Parental Affect
Parental affect is one of the few variables related to the
parent that has been studied in relationship to PID. While
some studies have found that PID is associated with higher
maternal negative affect (Wildman et al., 2004) and
maternal psychopathology (Dulcan et al., 1990), others
have found that negative affect is associated child psy-
chopathology (Ashman, Dawson, & Panagiotides, 2008)
but not necessarily PID (Briggs-Gowan et al., 2000).
Although previous PID research has focused exclusively on
negative parental affect, data indicate that positive and
negative parental affect are two orthogonal aspects of
mood that are related to behavior in separate and distinct
ways (Watson, Clark, & Tellegen, 1988). Assessment of
both aspects of mood provides a more accurate under-
standing of the contribution of affect than either alone
(Watson & Clark, 1997) and positive and negative affect
are predicted by different variables in parents (Pottie,
Cohen, & Ingram, 2009). Although it has not been exam-
ined in relation to PID, parental positive affect is also
associated with higher levels of problem solving skills
(D’Zurilla, Maydeu-Olivares, & Gallardo-Pujol, 2011;
Estrada, Isen, & Young, 1994), which may in turn be
related to seeking help for problems.
Parenting Style
Parenting discipline style, or the strategies that parents use
to manage child misbehavior, has been clearly linked to
development of child and adolescent behavior problems
(Alvarez & Ollendick, 2003). Specifically, parents who are
very harsh or very permissive with their children are more
likely to have children who are behaviorally aggressive
(Fabes, Leonard, Kupanoff, & Martin, 2001; Jones,
Eisenberg, Fabes, & Mackinnon, 2002) and anxious
(Wolfradt, Hempel, & Miles, 2003). When seeking advice
on parenting practices, parents tend to want advice from
their PCP (Schultz & Vaughn, 1999) and view this advice
as more important than other sources (Cheng, Savageau,
DeWitt, Bieglow, & Charney, 1996; Harwood, O’Brien,
Carter, & Eyberg, 2009). PCPs may also obtain informa-
tion on maladaptive parenting practices from conversations
with the parent regarding their parenting or from obser-
vations during a visit, such as witnessing excessive parental
reprimands, parental ambivalence towards child misbe-
havior, or ineffective limit setting.
Parental Self-Efficacy
Parenting self-efficacy can best be conceptualized as a par-
ent’s beliefs in their own ability to influence their child and
their child’s environment in a way that fosters the child’s
J Clin Psychol Med Settings
123
development and success (Ardelt & Eccles, 2001). Previous
research has demonstrated that lower levels of self-efficacy
predict higher rates of help-seeking (Coleman & Karraker,
1998; Judd et al., 2006) and participation in parenting pro-
grams (Telleen, 1990). However, these previous studies were
conducted in community mental health programs and not in
medical settings. Therefore, assessing this variable in rela-
tion specifically to PID may provide further information on
whether self-efficacy is similarly negatively associated with
obtaining help in primary care settings.
Parental Demographic Variables
In addition to parental characteristics demographic vari-
ables, such as parental race, socioeconomic status, insurance
type, child gender, and single parent status, have all been
assessed in relation to PID. However, all of these variables
have been found to be significantly associated with PID in
some studies, but not others (Briggs-Gowan et al., 2000;
Brown & Wissow, 2008; Dulcan et al., 1990; Gardner et al.,
2000; Glied, Hoven, Moore, Garrett, & Regier, 1997; Hor-
witz, Leaf, Leventhal, Forsyth, & Speechly, 1992). The
present study sought to add to the research literature by
examining the impact of these demographic variables on
PID, and to control for their influence when examining the
relationship between PID and other parent-related factors.
Study Hypotheses
The goal of the present study was to assess the potential role
of parent-focused variables other than demographics and
psychopathology on PID. We hypothesized that parental
characteristics would significantly aid in predicting which
children were identified by their PCP over and above the
impact of these variables on child behavior. Specifically,
higher levels of parental positive and negative affect, higher
levels of maladaptive parenting strategies, and lower levels
of parenting self-efficacy were hypothesized to predict a
higher level of PID. We also hypothesized that these parental
characteristics would add significantly to the prediction of
PID over and above demographic control variables and child
symptoms. Finally, we assessed whether these findings were
consistent across practices, given previous research that
pediatricians and practices vary in their likelihood to identify
behavioral problems (Brown, Riley, & Wissow, 2007).
Method
Procedure
Institutional review board approval was obtained at the
academic institution and hospital system of the authors.
The data for this study were collected as part of a larger
study assessing parental utilization of behavioral health
services provided in and near primary care pediatric prac-
tices. Participants were a convenience sample of parents
and legal guardians of children scheduled for well child or
acute care appointments in four community-based primary
care pediatric practices, all of which were affiliated with
the same regional pediatric hospital in northeastern Ohio.
Undergraduate research assistants approached parents in
the waiting rooms, explained the study, and obtained
consent. Data were not collected regarding the refusal rate
of participants in this study. PCPs were also consented to
participate before the study began. In order to be eligible to
participate, the adult with the child was required to be the
parent or legal guardian of the target child and the child
had to be between the ages of 2 and 16 years old. No
pediatricians refused to participate in the study. Parents
were given all measures to complete in the waiting room
and, if necessary, were given the option of completing
them while in the exam room, waiting for their child’s
PCP. A physician checklist was attached to the patient’s
chart by the office staff and pediatricians completed and
returned the physician checklist immediately after their
visit with the child.
The data for the present study were originally collected
as part of a study that provided outpatient behavioral parent
training to parents referred for services from the affiliated
primary care practices. Data were collected over three
years between 2004–2007. All primary care practices were
chosen based on affiliation with the hospital system and
were within a 15 miles, 30 minute drive to the hospital. We
also sought to have locations from both urban and suburban
settings. Sites A and D were both located in urban loca-
tions, whereas sites B and C were located in suburban
locations. The number of PCPs in each office varied from
2–4, including both full and part-time PCPs, leading to a
total of 13 full-time equivalent PCPs. All PCPs completed
pediatric residencies and were either board certified or
board eligible; most board certified. The PCPs ranged in
age from 29–71 years, 78% were female, and 82% were
Caucasian. However, the specific physician and practice
data were not collected by practice as part of the original
study.
Participants
A total of 1,457 parents consented to participate in the
study, of which 831 were included in the final analysis;
lack of a completed physician checklist accounted for most
of the parents who were eliminated from the sample.
Descriptive data for participants included in the analyses,
as well as comparative statistics between identified and
non-identified cases can be found in Table 1 and
J Clin Psychol Med Settings
123
demographic information by each practice site can be
found in Table 2.
Parents ranged in age from 19 to 68 years old (M =
34.24, SD = 7.46, Median = 34.0), with children rang-
ing from ages 2–16 years old (M = 6.79, SD = 3.75,
Median = 6.0). The majority of parents identified them-
selves as Caucasian (78.9%), with a sizable minority of
African Americans (15.4%). The vast majority of parents
who participated were female (91.5%). Few participants
identified themselves as Asian, Hispanic, other, or biracial,
so these ethnic groups were collapsed into a group col-
lectively called ‘‘other’’ (5.9%) for final analyses because
each group alone was too small to be included in the
analyses individually. The percentage of male and female
children about whom parents reported was roughly equal
(52.6 and 47.4%, respectively).
Measures
Demographic Questionnaire
The Demographic Questionnaire was used to obtain
information about the parent and child’s age, gender, eth-
nicity, education, insurance coverage, and single parent
status. Educational attainment and type of medical insur-
ance were used as proxies for SES.
Eyberg Child Behavior Inventory (ECBI) (Eyberg &
Pincus, 1999)
The ECBI is a 36-item parent report of externalizing child
behavior problems with established reliability and validity.
Each item describes a problem behavior that the parent
rates on a scale of 1–7 how often the behavior occurs in
their child. The sum of these scores composes the Intensity
scale score, which ranges from 36 to 252, and has a clinical
cutoff of 131. For each item, the parent is also asked ‘‘Is
this a problem for you’’, to which they can respond ‘‘yes’’
or ‘‘no’’. The number of ‘‘yes’’ responses are summed to
form the Problem scale score, which ranges from 0 to 36,
and has a clinical cutoff of 15. A child who exceeds the
cutoffs on both scales is considered to have a clinically
significant level of behavior problems. Although the ECBI
Problem and Intensity scales have been shown to be dis-
tinct indicators of child behavior problem severity (Eyberg
& Pincus, 1999), only the ECBI Intensity scale score was
used in the present study due to a high correlation between
the ECBI Problem and Intensity scale (r = .75), which can
be problematic for the multivariate analyses used. In the
present study, the internal reliability of the ECBI Intensity
scale was .95 as measured by Cronbach’s alpha, demon-
strating adequate internal consistency.
Positive Affect Negative Affect Schedule (PANAS)
(Watson et al., 1988)
The PANAS is a 20-item dimensional measure of general
trait positive affect (PA) and negative affect (NA) with
established reliability and validity. Each item has an
adjective describing a feeling or emotion, and the respon-
dent records the extent to which they have felt this way
during the past few weeks on a scale of 1–5, with 1 indi-
cating that the feeling had not occurred at all, and 5 indi-
cating that it occurred extremely often. The PANAS has
Table 1 Descriptive data
comparing 716 not identified
and 115 identified children
ECBI Eyberg Child Behavior
Inventory, PANAS Positive
Affect Negative Affect
Schedule, PA Positive affect,
NA Negative affect, PSParenting Scale, PSOCParenting Sense of
Competence Scale
* p \ .05. ** p \ .01.
*** p \ .001
Variable Not identified Identified Statistical test
Mean (SD) ECBI intensity 92.1 (28.9) 116.1 (37.4) t (829) = 7.9***
Mean (SD) ECBI problem 5.1 (5.8) 10.0 (7.7) t (829) = 8.0***
% African American 15.1 17.4 v2 (1) = .4, ns
% Caucasian 79.1 78.3 v2 (1) = .1, ns
% Other ethnicity 5.9 4.3 v2 (1) = .4, ns
Mean (SD) parent age 34.1 (7.4) 35.1 (7.7) t (829) = 1.4, ns
% Female 48.5 40.9 v2 (1) = 2.3, ns
Mean (SD) child age 6.5 (3.7) 8.9 (3.4) t (829) = 6.7***
% single parent 29.2 44.3 v2 (1) = 10.6**
% Private insurance 49.5 31.6 v2 (1) = 12.7***
% Medicaid 48.5 65.8 v2 (1) = 11.7**
% Self pay 2.0 2.6 v2 (1) = .2,ns
Mean (SD) PANAS PA 35.7 (7.0) 34.1 (8.3) t (829) = -2.1*
Mean (SD) PANAS NA 17.2 (5.4) 19.5 (6.6) t (829) = 4.2***
Mean (SD) PS overreactivity 14.9 (5.0) 15.6 (4.8) t (829) = 1.3, ns
Mean (SD) PS laxness 12.3 (4.2) 12.3 (4.4) t (829) = -.03, ns
Mean (SD) PSOC efficacy 32.6 (4.3) 31.5 (5.0) t (829) = -2.3*
J Clin Psychol Med Settings
123
ten items for each dimension, with the scores for each item
in a scale added together to yield a total score for both the
positive and NA dimensions ranging from 10 to 50 for both
scales. The internal consistency of the PANAS over an
8 week period is strong for both PA (r = .58) and NA
(r = .48) and correlates highly with other measures of
affect (Watson et al., 1988). In the present sample, both
scales were highly internally consistent, with a Cronbach’s
alpha of .90 for PA and .84 for NA.
Parenting Scale
(Arnold, O’Leary, Wolff, & Acker, 1993)
The Parenting Scale is a 30 item measure of dysfunctional
parenting practices. Parents self-report, on a scale of 1–7,
the intensity with which they participate in particular
behaviors when disciplining their children. Recent factor
analyses support two scales: Laxness and Overreactivity
(Karaszia, van Dulmen, & Wildman, 2008; Reitman et al.,
2001). Both scales contain five items and range from
5 to 35. The scales measure parenting style consistent
with Baumrind’s parenting styles (Baumrind, 1968).
Specifically, parents with a permissive parenting style are
more likely to use inconsistent discipline or no discipline
for misbehavior, while parents with an authoritarian
parenting style are strict, rigid, and overly punitive
(Lagace-Seguin & d’Entremont, 2006). In the original
standardization sample, test–retest reliability over a two-
week period with a combined clinic and non-clinic sample
yielded correlations of .83 and .82 for Laxness and Over-
reactivity, respectively (Arnold et al., 1993). In the present
sample, the Cronbach’s alpha coefficient was .73 for the
Overreactivity scale and .71 for the Laxness scale, sug-
gesting adequate internal consistency reliability.
Parenting Sense of Competence Scale (PSOC)
(Johnston & Mash, 1989)
The PSOC is a 16-item scale used to assess parenting self-
efficacy and satisfaction with the role of being a parent.
The parent is given statements about their role as a parent,
and rates each item on a scale of ‘‘1’’ (strongly agree) to
‘‘6’’ (strongly disagree). The PSOC yields two subscales:
Efficacy and Satisfaction. We used the Efficacy subscale,
Table 2 Overall descriptive
data for all practice sites
ECBI Eyberg Child Behavior
Inventory, PANAS Positive
Affect Negative Affect
Schedule, PA Positive affect,
NA Negative affect, PSParenting Scale, PSOCParenting Sense of
Competence Scale
Practice site A B C D
M (SD) M (SD) M (SD) M (SD)
N 283 197 208 143
Child age (years) 6.36 (3.50) 7.63 (3.90) 7.04 6.49 (3.71)
Parent age (years) 32.47(7.33) 37.09(7.02) 32.49(7.33) 36.38(6.77)
Ethnicity frequency
Caucasian 252 (89.0%) 181 (91.9%) 106 (51.0%) 117 (81.8%)
African American 21 (7.4%) 3 (1.5%) 83 (39.9%) 21 (14.7%)
Other ethnicity 10 (3.5%) 13 (6.6%) 19 (9.1%) 5 (3.5%)
Child gender frequency
Female 144 (50.9%) 82 (41.6%) 92 (44.2%) 76 (53.1%)
Male 139 (49.1%) 115 (58.42%) 116 (55.8%) 67 (46.9%)
Single parent status
Single 90 (31.8%) 30 (15.2%) 110 (52.9%) 29 (20.3%)
Not single 190 (67.1%) 167 (84.8%) 98 (47.1%) 114 (79.7%)
No response 3 (1.0%) 0 (0%) 0 (0%) 0 (0%)
Medical insurance type
Medicaid 163 (57.6%) 61 (31.0%) 156 (75.0%) 36 (25.2%)
Private 107(37.8%) 129 (65.5%) 46 (22.1%) 102 (71.3%)
Self pay 9 (3.2%) 4 (2.0%) 2 (1.0%) 2 (1.4%)
No response 4 (1.4%) 3 (1.5%) 4 (1.9%) 3 (2.1%)
ECBI intensity 97.81 (32.37) 93.25 (28.73) 94.88 (33.69) 94.55 (28.69)
ECBI problem 6.20 (6.62) 5.26 (5.60) 6.05 (6.61) 5.44 (6.30)
PANAS PA 35.42 (6.97) 35.36 (7.03) 34.86 (7.78) 36.59 (7.02)
PANAS NA 17.59 (6.01) 17.45 (5.51) 17.58 (5.42) 17.36 (5.47)
PS laxness 12.54 (4.40) 12.45 (4.08) 12.02 (4.25) 12.20 (4.01)
PS over reactivity 14.59 (4.88) 15.72 (4.89) 14.83 (5.19) 15.24 (4.64)
PSOC Efficacy 32.42 (6.97) 31.84 (4.76) 32.66 (4.46) 32.63 (3.88)
J Clin Psychol Med Settings
123
which is composed of seven items assessing the degree to
which a parent feels skilled and confident in handling their
child’s problems. This scale has a range from 7 to 42. The
factor structure of the PSOC has been replicated, and the
Efficacy scale is positively correlated with low-conflict
parenting style among mothers in an urban community
sample (Ohan, Leung, & Johnston, 2000). In the present
sample, the Cronbach’s alpha coefficient for the Efficacy
scale was .75.
Physician’s Checklist
The Physician’s Checklist is a brief, seven-item, question-
naire that was developed specifically for this study, and is
based on previous research (Lynch, Wildman, & Smucker,
1997; Yerkey & Wildman, 2004). It contains information
on whether or not the physician has concerns about the
psychological functioning of the child, parent, or other
family member; whether the child is currently being treated
for a behavioral problem; the nature of the physician’s
concerns; and what, if anything, they did about their con-
cerns. Pediatrician identification (PID) was operationally
defined as the PCP reporting concerns about the behavioral
or emotional functioning of the child, treating the child for a
behavioral or emotional problem, or referring the child to
mental health services.
Missing Data
From the initial pool of 1457 participants, 831 participants
were included in the final analyses. Reasons for exclusion
from analysis included a missing or incomplete Physician
Checklist (n = 511), incomplete (\80% complete) par-
enting measures (n = 104), and participants who were
multivariate outliers (n = 11). Separate logistic regressions
were conducted to examine patterns in missing data based
on demographic variables. Missing data was not related to
child age, parent age, insurance type, single parent status,
or PID; however, African-Americans were less likely to be
included in the final analyses than Caucasians (B = -.455,
p = .002).
For participants who were retained for final analyses,
81.8% of all possible data points had complete data. In
order to include as many participants as possible in the final
analyses, missing data on all parenting measures, with the
exception of the demographic questionnaire, were imputed
using an expectation–maximization (EM) imputation
algorithm available in EQS 6.1 (Bentler, 2004). This
strategy was used because EM imputation yields more
accurate standard errors than listwise or pairwise deletion
(Acock, 2005; Bentler, 2004). This strategy may have
created values that are slightly biased towards Caucasian
participants because African Americans were more likely
to have missing data points in the present sample. How-
ever, the sample would have been similarly biased if list-
wise deletion had been used to delete participants with any
missing data points (n = 409). Therefore, this strategy was
utilized to increase power and include participants who
were missing no more than two items on any given mea-
sure by using a method with less bias than listwise deletion
or mean imputation (Acock, 2005).
Analysis Plan
All major study questions were assessed using logistic
regression. This type of analysis was chosen because it
allows for examination of the multivariate influence of both
categorical and linear variables on a dichotomous outcome
variable without requiring normal distributions of the
variables (Tabachnick & Fidell, 2001). For the present
analysis, this strategy allowed us to examine whether
parent variables uniquely predicted PID over their rela-
tionship to demographic variables and child behavior.
Control and parental variables were entered simultaneously
into one equation because, in a given office visit, a PCP
does not see one aspect of a parent, but must look at the
parent and child as a whole in a short amount of time. As
such, all variables were entered in the same equation and
evaluated in the context of one another, just as the PCP
sees these variables in the context of one another during the
visit. To select control variables, identified and non-iden-
tified children were compared on all demographic variables
and the ECBI Intensity scale score. These comparisons
were conducted by using t-tests for all continuous variables
and chi-square analyses for all categorical variables. All
significant control variables were used as control variables
in all subsequent analyses. For all logistic regressions, PID
was the dependent variable, with identified patients coded
as ‘1’ and non-identified patients coded as ‘0’. A logistic
regression was conducted on the overall sample, including
all significant control variables, as well as parental affect,
parental self-efficacy, and parenting style. This logistic
regression was repeated for each practice site to explore
whether the patterns of significant parenting factors were
the same across practices.
Results
Control Variables
Chi-squares and t-tests were used to compare identified and
non-identified participants on parent ethnicity, parent age,
child gender, child age, whether or not the parent was a
single parent (coded ‘1’ for single parents, and ‘0’ for not
single parent), type of medical insurance, and severity of
J Clin Psychol Med Settings
123
child behavior. The results of these analyses are summa-
rized in Table 1. The children in the identified group were
statistically significantly older (t (829) = 6.7, p \ .001),
more likely to have a single parent (v2 (1) = 10.6, p \.05), less likely to have private health insurance (v2
(1) = 12.7, p \ .001), more likely to have Medicaid health
insurance (v2 (1) = 11.7, p \ .01), and had a greater
number of behavioral symptoms (t (829) = 7.9, p \ .001)
than participants who were in the not identified group.
All subsequent logistic regressions controlled for these
variables.
Overall PID Analysis
The results of the regression assessing the impact of par-
enting factors for the overall sample can be found in
Table 3. For the overall sample, parental overreactivity
was the only parental variable statistically significantly
related to PID, with lower levels of parental overreactivity
associated with a higher likelihood of PID (B = -.075,
p \ .01, odds ratio = .928, 95% CI. 877–.981).
Separate Practice Site Analyses
Logistic regressions were conducted separately for each
site, including the same control variables and parenting
factors as the other analyses. The results of the stepwise
logistic regressions for sites A–D were different across
sites. At site A (n = 283), the only statistically significant
predictor of PID was parental self-efficacy, with lower
levels of parenting efficacy predicting a higher likelihood
of PID (B = -.134, p \ .05, odds ratio = .875, 95% CI.
769–.995). For site B (n = 197), none of the variables
significantly predicted PID. For site C (n = 208), overre-
activity (B = -.090, p \ .05, odds ratio = .914, 95% CI
.837–.999) was statistically significantly associated with
PID, with lower levels of overreactivity predicting a higher
likelihood of PID. For site D (n = 143), none of the
parental variables were statistically significantly associated
with PID.
Discussion
Most research on the process of PID to date has focused on
pediatrician factors, maternal psychopathology, or demo-
graphic variables (Briggs-Gowan et al., 2000; Gardner
et al., 2000; Horwitz et al., 2007). However, other parental
processes underlying PID have been virtually ignored. The
findings of the present study highlight the contributions of
parental factors, outside of maternal psychopathology, to
whether or not a child is identified by their PCP as having a
behavior problem. In this Midwestern sample, parents who
felt less confident in their parenting skills or were higher in
authoritarian parenting were less likely to have children
who were identified by their PCP. Differences were found
in which variables predicted PID across practices, sug-
gesting that PID is potentially influenced by both PCP and/
or practice variables, as well as parent variables, and
should therefore not be viewed as a uniform process across
PCPs and practice settings.
Given that parents are the primary source of information
about their child during pediatric primary care visits (Cos-
tello & Edelbrock, 1985), it is not surprising that parenting
factors play a role in PID. Parental emotions and values
affect how a parent evaluates whether their child’s behavior
is problematic (Weisz & Weiss, 1991) and subsequently
discloses a concern to their child’s PCP. A strength of this
study is that it tested the potential contribution of parental
factors in PID empirically. Although the results of this study
support the inclusion of parental factors in PID research, the
relationship between parenting style and PID was in the
opposite direction of what was hypothesized. Specifically,
parents with a more authoritarian, or overly rigid and
punitive, parenting style were less likely to have their child
identified by their child’s PCP as having a behavioral dif-
ficulty. This finding is particularly striking, given that this
type of parenting style is associated with a higher likelihood
of PID (Alvarez & Ollendick, 2003; Fabes et al., 2001). A
potential explanation for these findings could be that parents
with this type of controlling parenting style may believe that
their approach is effective or correct. Additionally, parents
who use a harsh discipline style may fear that they will be
Table 3 Summary of logistic regression analysis predicting PID
from parent variables for overall sample (N = 815)
Predictor B SE B eB 95% CI
ECBI intensity .027*** .004 1.027 1.019–1.035
Child age .236*** .032 1.267 1.189–1.349
Single parent status .132 .252 1.141 .697–1.869
Medicaid .500^ .263 1.648 .984–2.759
Self pay .110 .739 1.116 .262–4.749
PANAS PA -.007 .017 .993 .961–1.027
PANAS NA .026 .020 1.026 .987–1.068
PS overreactivity -.075** .028 .928 .877–.981
PS laxness -.035 .030 .966 .911–1.024
PSOC efficacy -.013 .028 .987 .935–1.042
Constant -4.947
v2 127.071***
df 10
% Identified 14.0
ECBI Eyberg Child Behavior Inventory, PANAS Positive Affect
Negative Affect Schedule, PA Positive affect, NA Negative affect, PSParenting Scale, PSOC Parenting Sense of Competence Scale
^ p \ .07. * p \ .05. ** p \ .01. *** p \ .001
J Clin Psychol Med Settings
123
reported or have their children taken away from them.
Indeed, parents report that a common reason for not seeking
help from their child’s PCP is that they are afraid their child
will be removed from their home (Sayal et al., 2010).
Another possibility is that parents with this parenting style
in our sample may have been more likely to have children
with mood disorders (e.g. anxiety, depression; Luis, Varela,
& Moore, 2008) and parents are less likely to obtain treat-
ment for these types of disorders (Briggs-Gowan et al.,
2000). While these explanations are plausible, they cannot
be tested with the current data. This surprising relationship
suggests that parents who have a parenting style that puts
children at-risk for having behavior problems are also at
greater risk for not having these problems identified.
Therefore, a potential strategy for increasing PID may be to
increase PCP assessment of behavioral problems in parents
who are strict or authoritarian.
In addition to parenting style, the level of confidence
that parents have in their parenting skills may also play an
important role in whether a PCP identifies a behavior
problems in the child. At one site in the present study,
children were more likely to be identified with parents who
had lower levels of parenting self-efficacy. This finding is
consistent with previous research, which suggests that
parents with low levels of parenting self-efficacy are more
likely to seek help for their child’s behavior (Coleman &
Karraker, 1998). This finding is somewhat encouraging,
suggesting that parents who are not confident in their
abilities are more likely to be recognized as needing help
by their child’s PCP. However, this also suggests that
children of parents who are more confident in their par-
enting abilities may be less likely to be recognized as
needing help by their child’s PCP. For parents who are
confident in a maladaptive parenting style, this could lead
to further dysfunction and a lack of identification of chil-
dren who are at risk. Taken together, the findings of
parental self-efficacy and authoritarian parenting suggest
that assessing parental factors outside of psychopathology
and demographic variables can increase our understanding
of PID. By continuing to examine parenting factors that are
associated with PID, future efforts can continue to identify
which families are likely to be missed by PCPs and inter-
ventions to target these families can be developed.
Clinical Implications
The results of this study have several important clinical
implications for PCPs. The finding that children of parents
with an authoritarian parenting style are less likely to be
identified by their PCP indicates the need for conversations
between PCPs and parents regarding parenting/discipline
style. Follow up questions about PID in children of parents
with an authoritarian style may help to increase PID even if
parents do not initially disclose concerns about behavior.
Parents view their child’s PCP as a trusted source of par-
enting advice (Harwood et al., 2009; Keller & McDade,
2000) and over 80% of parents wish that their child’s PCP
would discuss behavioral and family issues more often
(Halfon et al., 2002). However, time constraints may pre-
vent PCPs from engaging in discussions of parenting
approaches with all families (Horwitz et al., 2007). A
strategy to determine which families may warrant a dis-
cussion of parenting practices would be the use of
screening instruments designed for use in primary care,
such as the Pediatric Symptom Checklist (Pagano et al.,
2000) or the ECBI (Eyberg & Pincus, 1999) in the waiting
room. Previous research has shown that using screening
measures assessing child behavior can help to increase
accurate PID (Chisolm et al., 2007; Murphy et al., 1992).
Using a brief screening instrument that specifically assesses
parenting practices may also help PCPs identify patients
who are at-risk for behavioral difficulties.
Limitations
The findings of the present study should be interpreted in
the context of several limitations. First, while these data
provided preliminary evidence that practices, and poten-
tially individual PCPs, may differ in which parenting fac-
tors play a role in PID, the lack of data regarding PCPs and
practices precluded analyses of the relationship between
specific practice variables and PID. Another limitation is
that there was a high rate of missing data for the Physician
Checklist. It is therefore possible that the sample is biased
toward certain types of PCPs or patients and may over or
under represent the relationships among the predictor
variables and PID. Since PCPs were not identified on any
of the forms in this study, it is also impossible to assess
whether certain physicians had more missing data than
others. Although parent ethnicity was not a significant
predictor of PID, this sample was more than 75% Cauca-
sian, and African American parents were more likely to
have missing data than Caucasian parents. Because of the
strategy used to impute missing data, this discrepancy may
have led to a sample with data that is somewhat biased
towards Caucasian participants. Analyses of ethnic differ-
ences were not conducted in the present study due to
sample size limitations. Finally, the measure of child
behavior used for this study, the ECBI (Eyberg & Pincus,
1999) measures only externalizing behavior problems, and
not internalizing problems, such as depression and anxiety.
Given that parents of children with internalizing problems
are less likely to detect problems and subsequently seek
treatment (Sourander, Helstela, & Helenius, 1999), the
process that leads to PID for these types of problems may
be different.
J Clin Psychol Med Settings
123
Research Directions
The present study offers directions for future research in
the study of PID. The potential impact of parenting self-
efficacy, parenting style, and parental affect on PID were al
examined. However, other parent-related processes, such
as social support, culture (Briones, Heller, & Chalfant,
1990), and/or the stigma associated with discussing
behavioral issues (Hinshaw, 2005) may also play a role in
PID. Although differences were found among the separate
practice sites in this study, further research is needed to
determine specific PCP or practice variables that contribute
to PID. This research should assess potential interactions
between parent/child and PCP variables to determine
which types of patients are least likely to be identified in
which practices. For instance, in the present sample, phy-
sicians who were not confident in their knowledge of
parenting practices and child behavior may have been less
likely to identify the parents with an over reactive par-
enting style than physicians who have been well-trained in
this area. If this were the case, then parenting style would
interact with physician confidence in their knowledge of
parenting practices. Similarly, at one site parents with
lower levels of self-efficacy were more likely to have
children identified by their child’s PCP. A possible expla-
nation for this finding may be that PCPs at this site had a
style that made parents more comfortable with discussing
their difficulties with parenting, whereas at other sites
parents may not have been as comfortable talking with
their child’s PCP. This would fit with previous research
indicating that parents disclose concerns regarding behav-
ior when they are comfortable with their child’s PCP
(Sayal et al., 2010). The relationship between PID and
parenting factors may also differ based on physician
communication style, practice environment, or availability
of mental health services (Horwitz et al., 2007; Brown &
Wissow, 2008). These differences between practices may
explain why previous studies have had inconsistent find-
ings regarding the relationships between demographic
variables and PID (e. g. Briggs-Gowan et al., 2000;
Gardner et al., 2000; Horwitz et al., 1992). By further
exploring the interrelationships among parent, child, and
PCP, variables, it will be possible to determine which
families are least likely to be identified by their PCP as
having a behavior problem and create targeted interven-
tions to address this problem.
In conclusion, the present study examined the potential
impact of parental factors in PID. Assessing parenting style
in primary care offices may help to increase PID because
parents with authoritarian parenting styles are less likely to
have children identified by their PCP. However, the
parental factors that impact PID vary depending on dif-
ferent practices, and further research is needed to examine
what type of PCP and practice factors moderate the rela-
tionship between parental variables and PID. Improving the
understanding of these interrelationships is necessary for
the development of effective interventions to increase PID
and decrease the level of unmet need for child behavioral
health care.
Acknowledgment This project was supported by a grant from the
Ohio Board of Regents and a grant from the Akron Children’s Hos-
pital Foundation.
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