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: Robert.M.Dempster@gmail.com

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

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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

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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

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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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