Pediatric Symptom Checklist Template printable pdf download

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Pediatric Symptom Checklist

he Pediatric Symptom Checklist is a psychosocial screen designed to facili-

tate the recognition of cognitive, emotional, and behavioral problems so that

appropriate interventions can be initiated as early as possible. Included here

are two versions, the parent-completed version (PSC) and the youth self-report

(Y-PSC). The Y-PSC can be administered to adolescents ages 11 and up.

INSTRUCTIONS FOR

The PSC consists of 35 items that are rated as “Never,” “Sometimes,” or

SCORING

“Often” present and scored 0, 1, and 2, respectively. The total score is calculat-

ed by adding together the score for each of the 35 items. For children and

adolescents ages 6 through 16, a cutoff score of 28 or higher indicates psycho-

logical impairment. For children ages 4 and 5, the PSC cutoff score is 24 or

higher (Little et al., 1994; Pagano et al., 1996). The cutoff score for the Y-PSC

is 30 or higher. Items that are left blank are simply ignored (i.e., score equals

0). If four or more items are left blank, the questionnaire is considered invalid.

HOW TO INTERPRET THE

A positive score on the PSC or Y-PSC suggests the need for further evaluation

PSC OR Y-PSC

by a qualified health (e.g., M.D., R.N.) or mental health (e.g., Ph.D., L.I.C.S.W.)

professional. Both false positives and false negatives occur, and only an experi-

enced health professional should interpret a positive PSC or Y-PSC score as any-

thing other than a suggestion that further evaluation may be helpful. Data

from past studies using the PSC and Y-PSC indicate that two out of three chil-

dren and adolescents who screen positive on the PSC or Y-PSC will be correctly

identified as having moderate to serious impairment in psychosocial function-

ing. The one child or adolescent “incorrectly” identified usually has at least

mild impairment, although a small percentage of children and adolescents turn

out to have very little or no impairment (e.g., an adequately functioning child

or adolescent of an overly anxious parent). Data on PSC and Y-PSC negative

screens indicate 95 percent accuracy, which, although statistically adequate,

still means that 1 out of 20 children and adolescents rated as functioning ade-

quately may actually be impaired. The inevitability of both false-positive and

false-negative screens underscores the importance of experienced clinical judg-

ment in interpreting PSC scores. Therefore, it is especially important for par-

ents or other laypeople who administer the form to consult with a licensed

professional if their child receives a PSC or Y-PSC positive score.

For more information, visit the Web site:

REFERENCES

Jellinek MS, Murphy JM, Little M, et al. 1999. Use of the Pediatric Symptom Checklist

(PSC) to screen for psychosocial problems in pediatric primary care: A national feas-

ability study. Archives of Pediatric and Adolescent Medicine 153(3):254–260.

Jellinek MS, Murphy JM, Robinson J, et al. 1988. Pediatric Symptom Checklist: Screening

school-age children for psychosocial dysfunction. Journal of Pediatrics 112(2):201–209.

Web site:

Little M, Murphy JM, Jellinek MS, et al. 1994. Screening 4- and 5-year-old children for

psychosocial dysfunction: A preliminary study with the Pediatric Symptom Checklist.

Journal of Developmental and Behavioral Pediatrics 15:191–197.

Pagano M, Murphy JM, Pedersen M, et al. 1996. Screening for psychosocial problems in

4–5 year olds during routine EPSDT examinations: Validity and reliability in a

Mexican-American sample. Clinical Pediatrics 35(3):139–146.

Pediatric Symptom Checklist Template

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