78 ASSESSMENT OF BEHAVIORAL
ADJUSTMENT AND
BEHAVIORAL STYLE
William B. Carey
This chapter presents suggestions on how a pediatrician
in private or clinic practice can evaluate children’s be-
havior competently without the aid of allied disciplines.
Techniques used by those specialists are discussed in
later chapters.
Some terms should first be clarified. Elsewhere in
this book, the point has been made that development
and behavior are intertwined in the individual. Never-
theless, they can be assessed separately. Development
refers to the evolution of capacities that is a reflection
of the maturation of the central nervous system (see
Chapter 79). The term behavior refers to the content
and style of the actions of a child in his or her relation-
ships, the way abilities are used. The first part of this
chapter discusses assessment of behavioral adjustment,
which is the content of these actions. The second part
deals with temperament, which is the style with which
they are ­performed.
BEHAVIORAL ADJUSTMENT
Challenge and Obstacles
The proficient evaluation by the pediatrician of behav-
ior in children is a complex challenge. Much is expected
of the pediatrician. Ideally, every comprehensive pediat-
ric appraisal and especially every investigation of a spe-
cific problem with possible developmental-behavioral
components, such as headaches or scholastic difficulties,
should include a clear picture of the child’s behavioral
adjustment pattern; the physical, developmental, tem-
peramental, and environmental factors interacting with
them; and a plan for possible alteration of these factors
for the benefit of the child. An astute clinician should
have the child’s development and behavior in mind in
every encounter. Besides well-developed interviewing
and counseling skills, this expectation presumes an un-
derstanding of whether specific behaviors are normal,
and, if not normal, a judgment as to how severe they
are, why they have developed, and what to do about
them. These objectives represent a major shift for the
practice of pediatrics, which emerged a century ago
as the subdivision of medical science dealing with the
nutritional and growth problems and physical diseases
then prominent in childhood.
In rising to meet this challenge, the pediatrician is
confronted with major obstacles, as follows:
1. Unclear presentation of concern by parents. Com-
pared with most common physical illnesses, behav-
ioral problems are likely to manifest clinically in
confusing, unorganized forms. The concern may be
evident, but its real focus may be obscure. The parent
might ask the pediatrician for advice on discipline,
when the true distress is marital discord and the
accompanying disputes over childrearing. Another
parent might request a different formula or com-
plain about intestinal gas, when the actual problem
is excessive crying in the infant. The concern must be
clarified before the diagnosis can begin.
2. Undefined parental expectations. A parent’s mention
of certain behavioral issues does not mean that he or
she is asking for or expects the involvement of the
pediatrician. The parent may simply be ventilating
dissatisfaction. The expectations of the parents may
be inappropriate. A discussion must occur as to what
the parents want and what the pediatrician can offer.
3. Skill and time required. As with any other area of
clinical competence, evaluation of behavior requires
training to achieve the necessary skill. Most pediat-
ric residency programs expose trainees to an abun-
dance of tertiary care of major illnesses, but to a
minimum of experience fostering the knowledge and
skills of behavioral pediatrics. Graduates of these
programs report an understandable feeling of inad-
equacy. Even a pediatrician with the requisite skills
is confronted with many competing responsibilities
during the available time with the patient, and with
a reimbursement system that at present overvalues
mechanical procedures and underpays for time spent
in diagnostic interviewing and counseling.
4. Frequently confusing advice from mental health
specialists. Conflicting theories about the origins of
behavior problems and their management often leave
pediatricians confused. Examples of differing opin-
ions are evident in advice about sleeping arrange-
ments, handling of excessive crying, and the use of
spanking. The techniques suggested by spokesper-
sons of those disciplines may be unsuitable for pedi-
atric settings.
771
772 Part IX    Assessment
Confronted with these obstacles, some pediatricians
are tempted to avoid asking parents about behavioral is-
sues or try to evade them when brought up. Some pedia-
tricians give standard prescription advice for the problem
without fitting it to the needs of the particular child.
Other pediatricians refer immediately to a mental health
specialist all parents concerned about their children. The
extent of this common suboptimal performance is not
easily determined, but it is probably not as great as has
been estimated by more severe critics (Costello, 1986;
Horowitz et al, 1992; Lavigne et al, 1993). Following
is a discussion of the available diagnostic classification
systems and some existing techniques for obtaining the
data needed for classification.
Diagnostic Classification Systems
Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition
The most widely known of the diagnostic systems for
behavioral and emotional problems is the DSM-IV (Di-
agnostic and Statistical Manual of Mental Disorders, 4th
edition) by the American Psychiatric Association (1994).
This volume was preceded by several versions, starting
with the DSM-I in 1952, and has been most ­recently up-
dated by a minor revision, the DSM-IV-TR in 2000. The
current version subdivides overall diagnoses into five
components or axes: (1) clinical disorders, (2) person­ality
disorders and intellectual disability, (3) general medical
conditions, (4) psychosocial and environmental prob-
lems, and (5) global assessment of functioning. In the
last of these measures, the clinician indicates a ­general
judgment from 1 (persistent danger to self or others)
to 100 (superior functioning without any symptoms).
­Normality is not specifically defined, but is ­assumed to
be the lack of any of the conditions listed.
Because the DSM system has been virtually the only
one available to physicians in the United States for de-
cades, many have assumed that it is the best one possible.
Clinicians in pediatric care have increasingly become
aware of its limitations, however, as follows:
1. The DSM system is primarily intended for adults and
does not deal sufficiently with the variety of problems
and concerns facing children, their parents, and the
professionals trying to help them in primary care.
2. DSM diagnoses use the categorical “medical model”—
the diagnosis is either present or absent—a view that
does not fit well with the primary care pediatrician’s
experience with the wide variation of children’s
adjustment along several dimensions of function.
3. The DSM system does not recognize or describe
normal variations of behavior. The most favorable
­rating under Axis V is “Superior functioning in a
wide range of activities, life’s problems never seem
to get out of hand, is sought out by others because
of his or her many positive qualities.” Temperament
is not even mentioned. Consequently, many normal
variations of temperament are overdiagnosed, such
as an inattentive child who is functioning normally,
but who is supposed to be given the “subthreshold”
diagnosis of “attention-deficit/hyperactivity disorder,
not otherwise specified,” rather than simply being
considered normal.
The content of the new DSM-V is not fixed yet, but
there are signs that some leaders of American psychia-
try are dissatisfied with the current system of static, cat-
egorical disorders. Jensen and colleagues (2006) have
proposed changing to a system that is dimensional and
adaptational and takes into consideration the child’s
context and interaction with it.
Diagnostic and Statistical Manual for Primary
Care: Child and Adolescent Version
The American Academy of Pediatrics Task Force on
Mental Health Coding for Children (1996) developed
and published the DSM-PC (Diagnostic and Statisti-
cal Manual for Primary Care: Child and Adolescent
Version). The principal aim was to overcome all three
limitations mentioned regarding the DSM-IV and its
predecessors, and “to help primary care clinicians bet-
ter identify psychosocial factors affecting their patients
so that they can provide interventions when appropri-
ate, be reimbursed for those interventions, and identify
and refer patients who require more sophisticated men-
tal health care.” This was an interdisciplinary effort in
which psychiatrists and psychologists collaborated with
pediatricians on an approximately equal footing.
The DSM-PC includes two principal parts, a listing of
environmental situations that may affect children’s be-
havior (e.g., caregiving changes, educational challenges)
and a longer child manifestations section of problems
in 10 different areas (e.g., negative/antisocial behaviors,
somatic and sleep behaviors). Within each of these 10
“behavioral clusters,” the presentation of symptoms is
subdivided into three levels: (1) developmental varia-
tions, by which is meant normal behavioral variations
that nevertheless may attract the concern of the clinician
or the parent; (2) problems, which are behaviors serious
enough to disrupt the child’s social or scholastic func-
tioning, but are not severe enough to warrant a diagno-
sis of a mental disorder (e.g., a child who gets into fights
intermittently in school or in the neighborhood); and
(3) disorders, as defined by the DSM-IV. The framers of
the DSM-PC were required by the American Psychiatric
Association to incorporate the entire DSM-IV terminol-
ogy unaltered as the standard inventory of behavioral
diagnoses.
The DSM-PC was a big step forward toward design-
ing a diagnostic system more appropriate for use by
physicians for all sorts of behavioral concerns with chil-
dren. Some of the major limitations of the DSM series
have been eliminated. Many pediatricians have found
it useful. There are still some significant limitations,
­however, that must be overcome before it can achieve
its ­maximum value. These limitations are as follows:
1. Physical status. There should be a place to incorpo-
rate a consideration of the great variety of general
physical and neurologic factors affecting behavior.
The environment is not the only influence.
2. Temperament. The relegation of the formal presen­
tation of temperament to two paragraphs in the
 Chapter 78    Assessment of Behavioral Adjustment and Behavioral Style
­ re­amble of the environmental situations section and
p life, does not appear in either the index or the list of
scattered brief mention later betrays an insufficient rec­
ognition of its importance. Temperament variations
are one of the three principal sources of ­ behavioral
concern that parents bring to pediatricians (the others
being actual behavior dysfunction and misperceptions
of abnormality). Shyness and moodiness are men-
tioned in the DSM-PC, but most important traits, such
as high intensity, unpredictability, high persistence,
and sensitivity, are not included. The particularly
important trait of adaptability appears nowhere in the
DSM-PC. Through interactions with the environment,
temperament participates in the formation of physi-
cal, developmental, and behavioral problems; it affects
children’s responses to physical illnesses and use of
medical care; and it can alter the child’s environment,
with which he or she is interacting (see Chapter 7).
3. Development. The child’s developmental status
would be better listed as a component contributing
to the behavioral outcome, rather than as simply
another child manifestation.
4. Parent-child interactions. No suggestions are offered
as to how to describe the parent-child interactions
and the ways in which the environmental situations
may be influencing the symptoms in the child mani-
festations. This should be a primary focus of inter-
vention efforts, which necessitates its inclusion in the
diagnostic process.
5. Service needs. The DSM-PC has a useful section on
determining the severity of the behavioral problem,
but no place to indicate the service needs of the child.
The clinician who has evaluated the child should
indicate what level of care is needed, including
(a) anticipatory guidance or brief educational coun-
seling; (b) reassurance or individualized counseling
for bothersome normal variations; (c) intervention
counseling for mild to moderately severe situations
or behavior problems, which need more time; and
(d) referral counseling for major behavioral or emo-
tional disorders. The clinician generating the diag-
nosis is the individual best qualified to make this
determination about service needs. If the clinician
does not make the determination, that function would
be left to others, such as health insurance companies.
6. Summary profile. The DSM-PC resembles the DSM-
IV in presenting long lists of possible problems. In
contrast to the DSM-IV system with its five axes,
however, the DSM-PC does not suggest a way to put
all the findings together into a diagnostic profile (see
Chapter 85 for an example of how this could be done
in a pediatric setting).
7. Omission of ratings of strengths. The DSM-PC system
is still basically oriented toward the abnormal in that
there is no opportunity for the clinician to make note
of positive aspects of behavioral adjustment, such as
social competence, task performance, self-assurance,
and general contentment.
8. Omissions of influences and problems. The list of pos-
sible problems is long, but there are important gaps.
The powerful and pervasive environmental influ-
ence of television is not mentioned. Colic, the most
­common behavior problem in the first few months of
773
presenting complaints.
The developers of the DSM-PC acknowledged that
this was a first attempt, and that revisions are inevitable.
Usefulness of the DSM-PC in its present state has not
been established. Plans for revision still are not evident
more than a decade later.
International Statistical Classification
of Diseases and Related Health Problems,
10th Revision
The ICD-10 (International Statistical Classification of
Diseases and Related Health Problems, 10th revision)
by the World Health Organization (1992) is, along
with the DSM series, the other best-known diagnostic
scheme. As the name implies, it also deals only with
disorders. The disorders listed as having their onset in
childhood and adolescence include hyperkinetic disor-
ders, conduct disorders, mixed disorders of conduct and
emotions, emotional disorders, disorders of social func-
tioning, and tic disorders. Much effort was expended by
the developers of this system and of the DSM-IV to make
the two classification systems as convergent as possible.
Nevertheless, some significant differences can be found
in criteria for diagnoses, such as with the unequal defini-
tions of hyperkinesis and attention-deficit/hyperactivity
disorder.
The International Classification of Functioning,
Disability and Health (ICF) offers a comprehensive
summary of physical and mental functions, activity
limitations, and environmental factors (World Health
Organization, 2001). However, it has few applications
in general pediatrics practice.
Diagnostic Classification: 0-3. Diagnostic
Classification of Mental Health and
­Developmental Disorders of Infancy
and Early Childhood
Another of the diagnostic procedures available to child
health care practitioners is the DC: 0-3 (Diagnostic
Classification: 0-3. Diagnostic Classification of Mental
Health and Developmental Disorders of Infancy and
Early Childhood) by the National Center for Clinical
Infant Programs (1994). The DC: 0-3 was offered as “a
systematic, developmentally based approach to the clas-
sification of mental health and developmental difficulties
in the first four years of life.” Following the example of
the DSM series, it offers the advantage of organizing the
diagnosis into five axes: (1) the primary diagnosis; (2) the
relationship classification; (3) physical, neurologic, and
developmental disorders and conditions; (4) psychoso-
cial stressors; and (5) functional emotional developmen-
tal level. The breadth of this approach is promising, but
it has some drawbacks. The DC: 0-3 also fails to include
temperament in any appropriate way. There is brief men-
tion of it in the ­introduction, but it is not incorporated
into the model except as traits such as sensory threshold
and ­adaptability become entwined as part of the abnor-
mality in the “regulatory disorders” diagnoses.
774 Part IX    Assessment
A revision, the DC: 0-3-R, was published in 2005. It
makes some important changes in terminology, but not
in the general format. There is still room for improve-
ment, such as the addition of child and parent strengths
(Sturner et al, 2007).
Comprehensive Child Assessment
Reasonable expectations for the performance of pedia-
tricians and the actual conditions of pediatric practice
call for a kind of diagnostic classification plan different
from those described previously. In an effort to over-
come all the defects in the systems mentioned, a compre-
hensive child assessment is offered here.
A good starting point in defining the relevant areas of
adjustment is to decide on what constitutes normality.
In Chapter 7, the point was made about how hard it
is to find a satisfactory definition of normality in chil-
dren’s behavior. Chess and Thomas (1986) have pro-
posed that social competence and task mastery be taken
as criteria for current normality and as goals of future
achievement. Chess also has revised an earlier textbook
definition of normality (see Chapter 7).
Building on these guidelines, one can tentatively con-
struct six general criteria for the assessment and rating of
behavioral adjustment. There is no one definitive way to
do this; the scheme proposed in Chapter 7 represents a
suggestion to be considered until something better evolves.
The following criteria are suitable for pediatric use in that
they include positive and negative aspects of the major
areas of adjustment and are easily applied (Table 78-1):
1. Behavior: relationships with parents, siblings, teach-
ers, other adults, peers, and others—social compe-
tence versus undersocialization (aggressiveness or
withdrawal).
2. Achievements: task performance, including work
and play—achievement versus underachievement or
excessive preoccupation with work or play.
3. Self-relations—self-assurance versus poor self-relations
or overconcern for self. Included here are self-care,
self-esteem, and self-regulation.
4. Internal status—reasonable contentment versus
symptoms of distress in feelings or thoughts.
5. Coping patterns: strategies typically used to deal
with the problems confronted in daily life—direct
and appropriate engagement versus ineffective, mal-
adaptive problem solving with overuse of defense
mechanisms, such as denial, avoidance, or repres-
sion. This poorly studied aspect of a child’s personal-
ity is probably derived from temperament, cognitive
capacities, and experience, especially parental rear-
ing practices.
6. Symptoms of physical functions: eating, sleeping,
elimination, gender/sex, unexplained physical com-
plaints, and repetitive behaviors—comfort versus
discomfort (Carey & McDevitt, 2004).
The internal consistency of these areas has been estab-
lished, and their assessment has been standardized with a
48-item questionnaire developed on a sample of 412 chil-
dren 4 to 14 years old seen in general pediatrics practices.
This scale is described further in the following section.
Table 78-1 provides a possible plan for organizing
information and judgments about a child’s behavioral
adjustment. The profile is separated into these six areas
of adjustment, and each of them is subdivided into five
levels of function, from excellent to good to satisfactory
to unsatisfactory to poor. Precise behavioral descrip-
tions for placement along these continua cannot be sup-
plied for all children, although it would be helpful if
that were possible. Criteria for these judgments depend
on various circumstances, such as age, sex, family, and
cultural settings. Strengths and liabilities are included.
Problems are considered as disruptions of various areas
of function, not with regard to the presence or absence
of “psychiatric” disorders. When these conclusions are
incorporated into a comprehensive diagnostic formula-
tion (see Chapter 85), they are accompanied by separate
judgments regarding the child’s physical health, neu-
rologic status, developmental level, temperament, and
interaction with the environment; a summary; and a
statement of service needs.
Child health profiles of this sort are rare in the medical
and mental health literatures (see Chapter 7). ­(Chapter 87
also describes behavioral assessment.)
Diagnostic Techniques
The usual techniques for obtaining data about children’s
behavioral adjustment to be incorporated into whatever
classification system is used are observations, ques-
tionnaires, and interviews. Observations of the child’s
behavior and of the parent-child interaction in the of-
fice setting can be highly illuminating to the diagnostic
process. These data are usually based on relatively brief
contacts, however, and might be atypical of the overall
picture. Long-term observations reported by teachers
and other caregivers can be more helpful. The physi-
cian’s own observations can confirm or raise doubts
about the history, but are seldom sufficient to replace
the history as the basis of the diagnosis.
Questionnaires concerning the child’s behavior can
make a useful contribution to the diagnosis if they are
descriptive and are used as part of the data-gathering
process, rather than by themselves as an oversimplified
diagnostic mechanism.
Interviewing is the pediatrician’s most powerful tool
for the assessment of behavior in children. No other
technique has the flexibility and subtlety of skillfully
allowing the parent or patient to describe and express
feelings about what is going on.
The two principal techniques for gathering diagnostic
information about behavior in common usage today are
(1) brief questionnaires for screening for psychopathol-
ogy for the purpose of referral or longer ones for greater
detail, and (2) a comprehensive pediatric assessment pri-
marily by interview that allows and promotes pediatric
management for most parental concerns about behavior.
Psychopathology Categorization Method
A common view of the role of pediatricians in behavioral
matters is that they should screen for behavioral distur-
bances, as they do for developmental delay and vari-
ous physical problems, so that they can refer ­ troubled
children to mental health specialists who are more
 Chapter 78    Assessment of Behavioral Adjustment and Behavioral Style 775

Table 78-1.  Comprehensive Profile of Behavioral and Emotional Adjustment

Areas of Adjustment/Definitions Ratings and Comments

Behavior����������������������������������
, Social
��������������������������������
Competence���������������
—Relationships with
�������������
People: a)  Highly competent, pleasant, likable
How Well Does Child Get Along with People? b)  More pleasing, likable than average
c)  Gets along moderately well; average
High social skills versus deficit d)  Some significant relationship problems, not major
Caring versus hostile, aggressive, destructive e)  Generally unpopular, often rejected
Cooperation versus opposition, defiance, manipulation Comments:
Involvement versus withdrawal
Autonomy versus dependence, overconformity

Achievements—Task Performance—School, Home, Other: a)  Excellent achievement

How Well Does Child Do Tasks and Play? b)  Good achievement
c)  Average, satisfactory achievement
Extent of achievement d)  Underachievement, not failing; excessive striving
Skill development, use e)  Poor achievement, failing; truancy
Motivation, effort, interest, responsibility Comments:
Satisfaction, pride in accomplishment

Self-Relations—Self-Assurance and Management: a)  Excellent self-esteem, self-care, and self-regulation

How Does Child Feel About and Manage Self? b)  Good status in these areas
c)  Variable, average status
Self-esteem—mental and physical abilities, appearance, social worth d)  Below average in some of these matters
Self-care versus neglect, abuse, risks, overconcern e)  Poor; problems in some or all these areas
Self-regulation—appropriate versus overregulation or ­underregulation Comments:

Internal Status—General Contentment versus Disturbance a)  High but reasonable contentment
in Feelings or Thinking: How Does Child Feel and Think? b)  Comfortable feelings and thinking
c)  Average mixture of concerns
Feelings—degree of comfort or discomfort d) Unsatisfactory; disturbing but not crippling feelings of fear,
Thinking—clarity and reality versus distortion ­anxiety, depression, anger, guilt; or reality distortions,
phobias, obsessions, compulsions, delusions; post-traumatic
stress disorder
e)  Poor; major disturbance of feelings or thinking
Comments:

Coping—Problem Solving: How Well Does a)  Highly effective coping

Child Identify and Solve Problems? b)  Generally effective coping
c)  Satisfactory; average; variable
Identify problems versus denial d)  Unsatisfactory coping
Plan solution versus avoidance e)  Poor problem solving; excessive use of defensive strategies,
Work on solution versus passivity such as denial, giving up
Persist at solution versus give up Comments:
Make needed revisions versus perseveration
Seek appropriate help versus not

Symptoms of Body Function—General Comfort a)  Comfortable in all areas

of Body Functions versus Discomfort or Dysfunction b) ���������������������������������������������
Generally good function; only minimal concern
c) ���������������������������������
Some concern; within normal range
Eating d) �������������������������������
Significant concern; not severe
Sleeping e) �������������
Major concern
Elimination Comments:
Gender/sex
Pains
Repetitive behavior
General Assessment

Main Service Needs

­ roficient with these issues (Costello, 1986; Jellinek

p and in ­Pediatrics in Review (Glascoe, 2000; Perrin and
et al, 1986). A dozen or more of these screening check- Stancin, 2002).
lists are available—brief checklists (<10 minutes), lon­ Among the best known of the brief checklists are the
ger ones, and ones designed for special areas of function. Pediatric Symptom Checklist (Jellinek et al, 1986), Ey-
Detailed analyses of their characteristics can be found berg Child Behavior Inventory (Eyberg and Ross, 1978),
periodically in various reviews in the Journal of the Conners Parent Rating Scale (Goyette et al, 1978), and
American Academy of Child and Adolescent Psychiatry Parents’ Evaluations of Developmental Status (PEDS)
776 Part IX    Assessment
(1997). Some screening scales requiring more time in-
clude the Child Behavior Checklist ­ (Achenbach and
Edelbrock, 1983), Behavior Assessment System for
Children (BASC) (Reynolds and Kamphaus, 1992),
Brief Infant-Toddler Social and Emotional Scale
­(BITSEA) (Briggs-Gowen et al, 2004), Ages and Stages
Questionnaire: Social Emotional (ASQ:SE) (Squires
et al, 2002), Devereux Early Childhood Assessment
Program (DECA) (LeBuffe and Naglieri, 1999), and
­Vineland Socio-Emotional Early Childhood Scale
­(Sparrow et al, 1998).
Some additional scales are designed to evaluate spe-
cific areas of function, such as coping, self-esteem, or
social skills or of malfunction, such as depression, in-
attention, or autism. The reader is directed to specific
chapters addressing these matters for more extensive
information. The question of the accuracy and ethics of
screening all teenagers with a brief questionnaire to dis-
cover early signs of depression is discussed elsewhere.
The proposed advantages of these behavioral rating
scales are as follows:
1. They gather information from the informants with
the greatest experience with the child.
2. They include some behavior not likely to be observed
by the clinician, such as sleep.
3. They are inexpensive and efficient.
4. Some available normative data allow determinations
of deviations.
5. They provide quantitative assessments concerning
qualitative aspects of behavior.
Perhaps the most important use of such a screening
scale by a pediatrician may be to facilitate communica-
tion between the physician and the parent or teacher, in
that it indicates the physician’s concern for behavioral
issues and promotes discussion of them. Despite their
value in psychiatric research and practice, however, these
questionnaires all have significant problems that interfere
with their use in pediatric primary care, as follows:
1. The data produced are of little assistance in the iden-
tification and management of the common behav-
ioral concerns parents bring to pediatricians, such
as sibling quarrels and resistance to toilet training.
Screening and referral for major behavioral problems
is only a small part of the appropriate mental health
role of the pediatrician.
2. Although various claims are made of their psycho-
metric qualifications, no proof has been offered that
these questionnaires detect important abnormalities
any better than do a few appropriately phrased and
directed interview questions, or that they result in an
improvement in physician performance (Stancin and
Palermo, 1997). The true efficiency of these scales in
pediatric practice remains to be shown.
3. With rare exceptions, the available scales rate only
abnormalities and do not evaluate positive evidence
of behavioral adjustment, such as social competence
or self-esteem. The few questionnaires that evaluate
positive aspects include the Strengths and ­Difficulties
Questionnaire (Goodman, 2001) and Behavior and
Emotional Rating Scale (BERS) (Epstein and ­Sharma,
1998).
4. They are highly impressionistic. An item such as
“talks too much” measures the caregiver’s judgment
of what constitutes an excess of talking as much as it
does the actual quantity of the behavior in the child.
The parents are exercising the diagnostic judgment
that should be made by the clinician.
5. They usually give equal weight to ratings of problems
of unequal significance, such as nose picking and fire
setting.
6. They typically ask about the overall frequency of the
behavior without regard for its varying significance
in different settings, such as whether trouble paying
attention is a problem with listening to safety rules or
learning irregular verbs as well as with video games.
7. The context and the parent-child interaction are
typically neglected. Two exceptions are the Child
and Adolescent Psychiatric Assessment (CAPA)
­(Wamboldt et al, 2001) and Keys to Interactive Par-
enting Scale (Comfort et al, 2006). Because ­pediatric
counseling is likely to deal with the parent-child
interaction, any diagnostic system failing to uncover
that would be of limited value.
Critics in the mental health professions have com-
plained that pediatricians are not doing a good job in
this screening process and are failing to detect substan-
tial numbers of problems present. These conclusions
may be correct to some extent, but they say little about
the types and significance of problems being missed or
the consequences of delay in detection. A more appro-
priate analysis of this situation (Horowitz et al, 1992)
showed “when using a classification system developed
specifically for primary care settings, clinicians do iden-
tify a large number of children (with) psychosocial and
developmental problems.” Appropriately directed inter-
viewing has been shown to produce a higher yield of the
existing problems (Wissow et al, 1994).
Comprehensive, Dimensional View of Behavior
The BASICS Behavioral Adjustment Scale (BBAS)
(Carey & McDevitt, 2004) was developed in an effort to
overcome as many as possible of these problems for chil-
dren 4 to 14 years old. This scale was based on the view
of adjustment involving the six BASICS areas (Behavior
in social relationships, Achievements, Self-­relations, In-
ternal status, Coping, and Symptoms of body function-
ing) (see Chapter 7). This new scale is comprehensive
(covering all these areas), dimensional (positive and
negative), descriptive, and useful for clinical practice. It
was standardized on a sample of more than 400 children
seen in general pediatric practices. It can be completed
by the parent in about 15 minutes and scored by a sec-
retarial helper in 2 to 4 minutes. Psychometric qualities
are good internal consistency and retest reliability and
discriminant validity. It can be used as a further assess-
ment of adjustment after the clinician has determined
some degree of parental concern about the child and de-
sires an efficient way to obtain a broader inventory. Cli-
nicians can use these ratings as a starting point to focus
for further interviewing and observations.
 Chapter 78    Assessment of Behavioral Adjustment and Behavioral Style 777

The Psychodynamic Diagnostic Manual (PDM) Define the Concern

of the PDM Task Force (2006) is a welcome psycho-
analytical addition to comprehensive systems in that
it considers both healthy and disordered personality
functioning. Its applications in pediatrics have not yet
been evaluated.
Diagnostic Procedure
This chapter urges the view that pediatricians should
make use of a comprehensive child health profile, such
as the one outlined in this chapter, and that the best way
to obtain the necessary data is by parent ­ interview as
supplemented with interview data from others, observa-
tions, and appropriate information from ­questionnaires.
Before undertaking the actual assessment of the behav-
ioral adjustment, the clinician is well advised to take
two preliminary steps: defining the concern and clarify-
ing the goals (Fig. 78-1).
The first step in the clinical assessment of behavioral
adjustment is to clarify what areas of behavior arouse
concern either from the caregivers or from the clinician.
General parental concern is easily derived from a few in-
troductory questions, such as “How are things going?”
or “What sorts of things bother you at this point?”
or “What kinds of problems are particularly trouble-
some now?” Queries more focused on behavior include
“What is your child like these days?” or “How is your
child’s behavior now?” or “How is your child getting
on with life these days?” or “How has your child been
treating you lately?” This part of the diagnostic process
is neither difficult nor time-­consuming. The pediatri-
cian can talk with the parent or child about the general
nature of outstanding problems in a few minutes.

DEFINE MAIN CONCERN

Type, duration, frequency, severity, response of caregivers

CLARIFY GOALS
Help wanted? What kind? How much?

Yes No

DETERMINE OTHER CONCERNS

Serious?
A) BASICS behavioral profile:
Behavior: relationships Yes No
Achievements
Self-relations—regard, care, regulation
Internal status—thinking, feeling Intervention on behalf Express concern
Coping of child Offer other care
Symptoms of physical function Monitor
B) Physical, neurodevelopmental,
or cognitive problem? Yes or maybe
Evaluate
Medical management
PRELIMINARY DIAGNOSIS: BEHAVIORAL, Educational planning
EMOTIONAL, OR PHYSIOLOGICAL
DYSFUNCTION?
Yes No

Serious? Moderate? Minor?

Other management problems?

Severe, multiple, Related to temperament- Minor

or chronic environmental interaction? management STRESS FROM PARENTAL
TEMPERAMENT- MISPERCEP-
ENVIRONMENTAL TION
Yes No INTERACTIONS
Inexperience?
A) Social reaction style: Or parental
Evaluate Evaluate interaction adapt, mood, approach problem?
temperament & with other factors: B) Work style: attention,
interaction physical, cognitive, persistence, distractability,
environmental activity
C) Situational reaction
MANAGE- style: sensitivity, intensity
MENT

Mental health 1) Discuss and modify parent- 1) Recognize problem For inexperience—
specialist child interaction 2) Reorganize parental information.
referral 2) Discuss and modify psycho- understanding, management Counsel or refer for
social factors, including education 3) Relief for caregivers parental problems.

Figure 78-1.  Algorithm for management of parental concerns about a child’s behavior.
778 Part IX    Assessment
If concern about behavior either is expressed as the
reason for the visit or comes up in the course of this
initial inquiry, the interviewer should find out who has
the concerns, what the concerns involve, where the con-
cerns come from, and why the concerns emerge at this
time. If at the outset of a general examination, the care-
giver (or patient) reports complete satisfaction with the
child’s status and progress in all areas, the questioning
can be greatly abbreviated from what is described here.
Clarify the Goals and Make an Agreement
When the concern has been discovered, the next step is to
determine whether and to what extent family members
wish to have the clinician help them with it. The behav-
ioral issue may have been mentioned without any desire
for or expectation of intervention by the ­clinician. The
clinician must clarify the objectives of family members
and set goals for management. For behavioral issues, the
pediatrician does not simply take charge of the diagnos-
tic and therapeutic procedure as when presented with
physical illnesses such as otitis media or pneumonia. For
behavioral issues, the process of evaluation and manage-
ment is shared with family members, and an agreement
must be established as to what family members expect
and what the physician will provide. If family members
do not want help, the physician can only express ap-
propriate concern and monitor the problem, unless it
is so severe that intervention on behalf of the child is
mandatory. When this agreement is reached, the pro-
cess of diagnosis can continue: determining the child’s
general physical-­developmental-behavioral profile, and
establishing the preliminary diagnostic impression and
disposition.
Determine the General Physical-Developmental-
Behavioral Status: What Else Is Going On?
By means of the history, physical examination, and
sometimes laboratory data, the clinician needs to find
out what else is going on in the child’s life. In particu-
lar, more should be learned about function in the other
six BASICS areas previously mentioned and presented
in Table 78-1.
There is no established set of questions to open and
explore these areas. An inquiry regarding social com-
petence might be: “How skillful is your child at get-
ting along with people?” or “How is your child getting
on with adults these days?” or “How socially mature
does your child seem for a child of his or her age?” or
“How does your child get along with other children?”
or “What sorts of things happen between your child and
other people that do not seem right?”
The pediatrician can inquire as to task performance
with questions such as these: “How are things going at
school?” or “What does your child do best or least well
at school?” or “What does your child like most or least
about school?” or “To what extent is your child’s per-
formance up to his or her abilities?”
Self-assurance can be assessed by asking: “How does
your child seem to feel about himself or herself?” or
“What is your child most or least proud of?” or “How
well does your child take care of himself or herself?” or
“How much trouble does your child have controlling
impulses?”
Regarding internal status one might ask: “How
happy a child is your child?” or “What sort of worries
does your child have?” or “How mature is your child’s
thinking?”
Coping strategies can be sampled by asking questions
such as: “How does your child go about solving a tough
problem?” or “What does your child generally do when
things are not going well for him or her?”
Symptoms of physical functioning can be assessed
with various approaches such as: “What sort of physical
complaints does your child have that puzzle you?”
With an older child, the interview also should involve
the patient directly. With adolescents, the topics cov-
ered may be more specifically directed by the HEADSS
approach (Home, Education/employment, Activities,
Drugs, Sexuality, Suicide) or one of the variations on
this plan (see Chapter 7), but the results still can be con-
tained in the suggested diagnostic profile.
Assessment of the child’s interaction with the care­
givers and larger psychosocial situation generally sug-
gests directions for counseling.
Establish Preliminary Diagnostic Impression
and Disposition
It should be possible at this point to categorize the pa-
rental concern as a parental misperception of a problem
(annoying but normal temperament, related to their in-
experience, or distortions owing to their own problems)
or into one of three levels: a minor problem, which can
be dealt with adequately at the time; a more complex
issue requiring further attention from the primary care
physician at that time or later (mild to moderately severe
dysfunction in the child, such as colic or night waking);
or a major disturbance needing the more advanced skills
or greater time allotments provided by a mental health
specialist (significant dysfunction in the child, such as
persistent antisocial behavior, declining school perfor-
mance, or depression).
The objective of this diagnostic process is not only to
screen for psychopathologic conditions, as some critics
have suggested, but also to develop a more complete
picture of the child’s status: successes and failures of all
types and degrees. The specific tactics and amount of
time required for an individual child vary from several
questions in a few minutes to extensive interviewing
for more than an hour. A second or third visit might
be necessary to complete the evaluation, but a prelimi-
nary diagnostic impression generally can be gained in
several minutes by a skillful interviewer who knows the
family.
Judgments as to whether the behavior described is a
variation of normal, a temporary or isolated disruption,
or a deviation requiring pediatric or psychiatric inter-
vention depends on a knowledge of the range of normal
behavior in the child’s particular context, as is described
in Chapters 2 through 6, and on the application of the
criteria of satisfactory adjustment listed previously. The
more numerous, severe, and chronic the behavioral
symptoms, the greater the need the pediatrician has for
seeking help from a mental health specialist. One cannot
 Chapter 78    Assessment of Behavioral Adjustment and Behavioral Style
suggest a simple formula, such as a score on a behavior
checklist, for defining indications for referral for con-
cerns about behavior; much depends on the nature and
extent of the symptoms, the skills of the pediatrician,
and the quantity and quality of referral resources avail-
able. These matters are discussed further in Chapter 75
and Chapter 86.
BEHAVIORAL STYLE OR TEMPERAMENT
Because temperament is defined and described in
Chapter 7, this section is limited to a discussion of the in-
dications and techniques for temperament assessment.
Indications for Assessment
Routine Professional Care
Pediatricians can and should include a few screening
questions about temperament in their periodic evalua-
tions to know what kind of child they are dealing with,
and to look for evidence of stressful traits and concerns
requiring further investigation. Although routine formal
determinations of temperament of all children at certain
regular times by pediatricians or schools might become
an accepted practice some day, they are not now. No
convincing case has been made for such detailed assess-
ments if caregivers are generally satisfied with a child’s
current behavioral status and there are no discernible
areas of malfunction in the child. Possible problems of
compliance, uncertain value of the data, and misuse by
inexperienced individuals outweigh the potential advan-
tages at present (Carey and McDevitt, 1995).
Nevertheless, the general education of parents and
other caregivers about temperament is an important an-
ticipatory guidance role for pediatricians. Because these
discussions are not specific, they can be accomplished
without a formal assessment. Several books are available
for more extensive parent education (Carey and Jablow,
2005; Chess and Thomas, 1987; Keogh, 2003; Kristal,
2004; Kurcinka, 1998; Turecki and Tonner, 1989).
When Child Arouses Concerns
There are two principal indications for formal clinical tem-
perament determinations in children. In cases of behavioral
adjustment problems, it is helpful to determine the contri-
bution of the child’s temperament to the situation. Such
information can provide help in explaining the magnitude
and direction of the child’s symptoms, and it assists the
setting of realistic goals for any therapeutic intervention.
With appropriate alteration of the management by care-
givers, the reactive symptoms in the child should diminish
or disappear. Meanwhile, the parents and other caregivers
must learn to live in a more tolerant manner and be more
flexible with the child’s temperament, which is evidently
less changeable (Carey and McDevitt, 1995). It is hard to
determine how often this practice is followed.
The other principal situation for temperament de-
terminations is when there is caregiver concern about
the child’s behavior or the parent-child interaction, but
no definite behavioral adjustment problem is evident
yet. If the child has a “difficult” temperament or one
of the other “temperament risk factors,” and these
779
traits are causing a stressful “poor fit” (incompatible
relationship) with the values and expectations of the
parents or other caregivers, even without a secondary
or reactive behavior disorder, it is important for the
pediatrician to be fully aware of the child’s participa-
tion in the problem. If the friction is coming from such
a disharmonious interaction, the appropriate manage-
ment consists of (1) recognition of the true nature of
the dissonance, (2) revision of the understanding and
management by the caregivers, and (3) some sugges-
tions to the parents and others on how to find relief
from their own feelings of stress. Punitive discipline
for the child or psychotherapy for the parent or child
would be inappropriate. Figure 78-1 shows the timing
of these two uses of temperament data. Greater detail
about these techniques is available in several books
(Carey and McDevitt, 1995; Chess and Thomas, 1986;
Turecki and Tonner, 1989).
Techniques for Temperament Determinations
As mentioned earlier, there are three principal methods
for obtaining data relating to behavior: interviews, ob-
servations, and questionnaires. This is true for tempera-
ment and behavioral adjustment.
Interviews
The best-known interview technique for obtaining tem-
perament data is the one devised more than 50 years ago
by the New York Longitudinal Study by Thomas and
colleagues (see Chapter 7). Although this interview was
sufficient for the needs of the New York Longitudinal
Study, neither it nor any adaptation of it has found wide
usage in research or clinical practice (Chess and Thomas,
1996). Its flexibility makes it more sensitive to varying
situations, but it also is less capable of standardization.
Its length of 1 to 2 hours (plus ≥1 hours for dictation
and rating) allows great richness of detail to be devel-
oped in behavioral descriptions, but renders it impracti-
cal in any clinical and most research settings.
Nevertheless, clinicians can and often do use these
concepts in a much abbreviated form in practical situ-
ations. A much shortened interview of the clinician’s
own construction can yield usable data as long as the
clinician resists the temptation to generalize too readily
from insufficiently comprehensive descriptions, such as
just one instance of a trait. A parental impression of a
trait should be supported by illustrations in several set-
tings. Table 78-2 presents suggested areas of function
to investigate. The interview approach, adapted to the
particular needs of the occasion, is the most convenient
way to screen routinely for a “poor fit” or to obtain ab-
breviated temperament data when there is no need for a
more detailed analysis (Carey and McDevitt, 1995).
Observations
Daycare workers and teachers generally have extensive
contact with children, placing them in a good position
to form sound judgments of individual children. Pedia-
tricians should make use of their contributions. Primary
care clinicians usually witness only brief, sometimes
atypical samples of behavior. There is still no standard-
ized comprehensive observation technique for assessing
780 Part IX    Assessment

Table 78-2.  Clinician’s Impressions of Child’s Temperament

Based on interview and office observation. Instructions—This checklist is designed to aid child health
professionals in obtaining a rapid survey of any temperament
Name of child:
traits causing concern. It reminds the clinician of the main
Age: areas where the trait may be described or observed. All items
Date: for each trait may not apply to all children, especially younger
Professional rater: ones. Items appropriate for infants and toddlers come first. It
produces a broad description, not a score or diagnosis.
Parental informant:

Activity—Amount Approach/With-
of Physical Motion High Medium Low ? B drawal—Initial
Reaction to
During sleep
Novelty Approach Medium Withdrawal ? B
During meals
During play New foods
New sitter
During car ride
New place
During dressing
New clothes
Rate of eating
Visitors in home
While waiting Strangers
Going up, down stairs ­elsewhere
Walking with family Unfamiliar
Listening to music ­children
Watching TV New toy, game
New group activity
Entering, leaving
house Arrival social
event
Talking with parents
New situation

Rhythmicity, Adaptability—Flexibility,
­Predictability— Ease of Adjustment to
Physical and Change High Medium Low ? B
Behavioral- Change meal time
­Regularity Regularity Medium Irregularity ? B Change activities
Sleeping times Change routines
Hunger times Calming if upset
Amount eaten New places
Food choices Change family plans
Response to Settling arguments
parent Accepting new rules
Bowel habits Response to coax���
ing
Play schedule Response to mild
Doing chores ­punishment
Doing homework Response to firm punishment
Care of Major setbacks
­possessions
Order in own
room
Keep
­appointments

Intensity—Energy Distractibility—
of Responses to Intense Medium Mild ? B How Easily
Hunger External Stimuli Distract- Nondis-
Pain Affect Activities ible Medium tractible ? B
Happiness Soothability during
Anger pain or fear
Surprise While playing alone
Scolding Playing with friends
Disappointment Household noises
Praise Somebody walks by
Likes and dislikes By TV when reading
Teasing By conversation
when reading
Disapproval
Discovery
 Chapter 78    Assessment of Behavioral Adjustment and Behavioral Style 781

Table 78-2.  Clinician’s Impressions of Child’s Temperament—cont’d

Mood—Observed Sensory Threshold—

Reactions Positive ­Sensitivity to Stimuli,
and Friendly or Notices High Medium Low ? B
Negative Positive Medium Negative ? B Changes in taste
On awakening Changes in lighting
At bedtime Changes in sound
When tired Water temperature
When hungry Room temperature
During, after meals Texture of clothes
Frustrated Odors
Sick or injured Soiled diapers
When corrected Soiled clothes
During play Minor injuries
Asked to do chores Mild parental
During chores ­disapproval
Denied permission
New visitors in home

Persistence/
Attention Comments-
Span—How
Long ­Activities
Concerns of caregiver-
Pursued Persistent Medium Nonpersistent ? B
Practice physical
activity Impressions of clinician-
Interest in new
toy
Service needs and other plans-
Look at, read
book
Watch TV
Learning special
skill
Listening to
parent
Household
chores
Work on own
project
Doing homework
Care of pet,
garden
Difficult project
Resume task after
interruption
Resume play after
interruption

? = Does not apply or do not know.

B = Bother—refers to whether this specific item is a problem for the caregiver. If so, make a check mark.
For standardized questionnaires assessing temperament or behavioral adjustment, go to www.b-di.com.

temperament for clinical purposes. Various studies have
devised methods for use with particular investigations,
but these are not easily applicable elsewhere. Matheny
(1980) developed an elaboration of the behavioral items
on the Bayley development scale for ratings of tempera-
ment in the study of twins. This method requires trained
observers and has not been applied clinically.
Brazelton’s Neonatal Behavioral Assessment Scale
(1973) is regarded by some clinicians as an appropriate
way to determine “constitutional temperament.” De-
spite its considerable value for studying and dealing with
neonatal problems and for helping parents understand
their newborns, however, newborn behavior is primarily
affected by nongenetic prenatal and perinatal factors, is
not very stable even from one day to the next, and does
not provide an adequate view of the primarily genetically
determined temperamental characteristics that emerge
in the next few weeks. Comparison between newborn
behavior, as measured by the Brazelton scale, and later
temperamental traits has been hindered by these factors,
and by the fact that some of the newborn measures, such
as muscle tone, are not temperament variables, and that
782 Part IX    Assessment

Table 78-3.  Questionnaires for Measuring Temperament

Principal Questionnaires in English Using New York Longitudinal Study Categories*
Retest
Age Span Name of Test Authors No. Items Reliability Alpha References
1-4 mo Early Infancy Medoff-Cooper et al 76 0.69m 0.62m J Dev Behav Peditr
Temperament 14:230, 1993
Questionnaire (EITQ)
4-11 mo Revised Infant Temperament ­ Carey and McDevitt 95 0.86t 0.83t Pediatrics 61:735, 1978
Questionnaire (RITQ)
1-3 yr Toddler Temperament Fullard et al 97 0.88t 0.85t J Pediatr Psychol 9:205,
Scale (TTS) 1984
3-7 yr Parent Temperament Thomas et al 72 NA NA Thomas and Chess:
Questionnaire for Children ­Temperament and
Development. New
York, Brenman/Mazel,
1977
Teacher Temperament Thomas et al 64 NA NA Thomas and Chess:
Questionnaire ­Temperament and
Development. New
York, Brenman/Mazel,
1977
Teacher Temperament Keogh et al 23 0.69-0.88 NA J Ed Meas 29:323, 1982
Questionnaire short form
Behavioral Style McDevitt and Carey 100 0.89t 0.84t J Child Psychol Psychiatry
Questionnaire (BSQ) 19:245, 1978
Temperament Assessment Martin 48 0.53-0.81 0.6-0.9 Dept. of Psychology,
Battery for Children Univ. of Georgia,
­Athens, 1988
8-12 yr Middle Childhood Hegvik et al 99 0.87m 0.82m J Dev Behav Pediatr
Temperament ­ 3:097. 1982
Questionnaire (MCTQ)
13-17 yr Adolescent Temperament McDevitt and NA NA NA In press
­Questionnaire ­Shacknai
18-60 yr Adult Temperament Chess and Thomas 54 0.76m 0.82m Behavioral-Developmental
Questionnaire Initiatives, 1998

Other Principal Questionnaires Generally not Using New York Longitudinal Study Dimensions†

Colorado Childhood Temperament Inventory (CCTI)

Infant Characteristics Questionnaire (ICQ)
Infant Behavior Questionnaire (IBQ)
Reactivity Rating Scale (RRS)
Emotionality, Activity, and Sociability Scale (EAS)
Dimensions of Temperament Survey (DOTS)
Toddler Behavior Assessment Questionnaire (TBAQ)
Children’s Behavior Questionnaire (CBQ)
School Age Temperament Inventory (SATI)
Infant, Toddler, and Preschooler Questionnaires
Temperament and Atypical Behavior Scale
*Retest reliability and internal consistency (alpha) are given as median category (m) or total (t) values.
†Primarily for research rather than for clinical use.
NA, data not available.
The EITQ, RITQ, TTS, BSQ, MCTQ, Adolescent and Adult Questionnaires, and scoring software may be obtained through Behavioral-Developmental Initiatives
(B-DI), 14636 North 55th Street, Scottsdale, AZ, 85254. Telephone 800-405-2313. Web address: www.b-di.com. Online assessment of patients can be approved by
registering at www.ipasscode.com/register.

none of the scale items or clusters is the same in content
and dimensions as the nine temperament characteristics
of the New York Longitudinal Study.
Questionnaires
With the increased recognition of the theoretical and clini-
cal importance of temperament, and the lack of practical
ways of measuring it accurately by interview or observa-
tions, a series of parent and teacher questionnaires has
been developed. Table 78-3 lists a selection of the cur-
rently available scales. Most are intended for completion
by parents, but some are designed for ratings by teachers,
i­ncluding the Temperament Assessment Battery for Chil-
dren by Martin (1988). Table 78-3 does not include
(1) scales based only on observations, such as those by
Matheny or Brazelton; (2) techniques possibly assessing
temperament, but ostensibly measuring something else,
such as the Conners Parent and Teacher Rating Scales;
(3) scales in foreign languages; (4) unpublished scales;
and (5) earlier scales intended primarily for adults such as
those by Eysenck in 1956, Guilford and Zimmerman in
1956, Thorndike in 1963, and Strelau in 1972.
Sample items from a scale based on the New York
Longitudinal Study view, the MCTQ, are (1) “Runs to
 Chapter 78    Assessment of Behavioral Adjustment and Behavioral Style
where he/she wants to go” and (2) “Avoids (stays away
from, doesn’t talk to) a new sitter on first ­ meeting.”
These two items are assessing activity and initial re-
sponse or approach/withdrawal. They are rated as to
frequency from almost never, to rarely, to variable, usu-
ally does not, to variable, usually does, to frequently, to
almost always.
The questionnaires using the New York Longitudinal
Study formulation have several advantages, as follows:
1. They are briefer and more efficient than comparable
interview and observation techniques in that they
require only 20 to 30 minutes for the caregiver to
complete and about 10 to 15 minutes for the clinician
or an assistant to score. They are low in cost and high
in acceptability. Yet they are not excessively simple;
all but one have more than 48 items, and most have
90 to 100 items.
2. They are based on clinically relevant variables. All
nine characteristics, such as adaptability and mood,
have been shown to be clinically observable and some-
times related to clinical problems. Most of the other
research scales available use computer-derived com-
posite constructs, such as “surgency” and ­“effortful
control,” which are of uncertain clinical clarity or
pertinence (see Chapter 7).
3. They consist of specific behavioral descriptions
(e.g., “The infant moves about much [kicks, grabs,
squirms] during diapering and dressing”), rather
than parental perceptions or general impressions of
the child’s behavior (e.g., “Child is very energetic”).
4. They are standardized as to norms for characteristics
at various ages from 1 month through 12 years and
beyond.
5. They have adequate psychometric characteristics
regarding retest reliability and internal consistency
and validity as far as it can be evaluated.
Persisting uncertainties about this set of question-
naires include the following:
1. The question remains unresolved as to whether par-
ents with less than a high school education can respond
accurately to these scales. Parents with below average
verbal skills may not be able to handle adequately the
formation of balanced generalizations and the vari-
ous shades of meaning, leading to ­distortions.
2. Parents in cultures or subcultures different from those
of the standardization samples might understand the
items in dissimilar ways, especially when translated.
Not only translation, but also restandardization of
the entire scale is indicated in these situations (Carey
and McDevitt, 1995).
3. The issue of validity is not easily resolved. Behavioral
scientists currently have tended to speak of any paren-
tal judgments of temperament as “perceptions,” and
of their own data, no matter how brief and unrep-
resentative, as scientific “observations.” It would be
more appropriate to say that perceptions are general or
hasty impressions, and that ratings are a series of more
carefully considered judgments of certain ­ behavioral
­patterns in specific settings. Parents and ­professionals
783
can have perceptions and make ratings. The ideal test
of the validity of the parental ratings on a tempera-
ment questionnaire would be a ­ comparison with a
comprehensive standardized observational rating
scheme. As already mentioned, there is no appropri-
ately matched one in existence now. Every adequately
designed test so far has shown at least ­moderate valid-
ity of parental reports, however. Data from parents
must be contemporaneous and relate to specific behav-
ioral patterns, rather than general impressions. Com-
parisons of parental and ­ professional ratings must
involve the same content and dimensions of behavior,
a requirement overlooked in the few published reports
­claiming to ­ discredit the validity of parental ratings
(Carey, 1983). Clinical users of temperament question-
naires can be reassured of at least a moderate degree of
validity. Although distortions can occur, they can be
minimized by the interviewing and observations that
should always accompany the use of a questionnaire.
4. Several critical reviews of these and other psycho-
metric properties of the existing questionnaires have
been published by academic psychologists (Carey
and McDevitt, 1995). Although one can agree with
them that all the scales have their shortcomings, these
reviews suffer from a superficiality of analysis and
the absence of a clinical perspective.
In situations of clinical concern about behavior, the
best way to measure the contribution of the child’s tem-
perament to the interaction is by using one of the more
sophisticated questionnaires supplemented by observa-
tions and further history as needed. The briefer or more
impressionistic questionnaires used by some clinicians
in research, and the questionnaires presented in most
popular books and articles for parents are not likely to
be sufficiently objective and detailed for ­clinical use.
SUMMARY
Many pediatricians are unsure about how best to
­evaluate the behavior of their patients. For assessment of
behavioral adjustment, this chapter does not ­encourage
the use of screening checklists designed simply to select
children for referrals, and it does not support the exclu-
sive use of the categorical pathology diagnostic model.
Instead, it recommends a primary reliance on interview-
ing of the parent directed toward constructing a compre-
hensive descriptive behavioral profile with a limited use
of labels. For determinations of temperament in routine
care, a few interview questions generally are sufficient,
but in case of parental concern, a standardized question-
naire provides a fuller picture of the child’s contribu-
tion to the interaction. This enhanced evaluation puts
­pediatricians in a better position to fulfill their expected
role in dealing appropriately with parental concerns,
most of which do not need referral.
ACKNOWLEDGMENTS
My thanks to my colleague, Sean C. McDevitt, Ph.D.,
of Scottsdale, Arizona, for his helpful critical review if
this chapter.
784 Part IX    Assessment
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BOOKS RECOMMENDED FOR PARENTS
Carey WB, Jablow M: Understanding Your Child’s Temperament.
Philadelphia, XLibris, 2005.
Keogh BK: Temperament in the Classroom. Baltimore, Brookes,
2003.
Kristal J: The Temperament Perspective. Baltimore, Brookes, 2004.
Kurcinka MS: Raising Your Spirited Child. New York, Harper­Collins,
1991. Reissued 1998.
Turecki S, Tonner L: The Difficult Child (revised). New York, Bantam
Books, 1989.