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A significant number of preschool children with behavioral problems are not diagnosed or treated by their pediatricians. Sixty-eight pediatricians who saw 3,876 children for various physical ailments also observed the children for signs of emotional or behavioral problems. During the visit, the children's mothers completed a child behavior checklist used to screen for emotional and behavioral problems. Two experienced child psychologists then evaluated 495 children whose scores on the behavior checklist were in the top 10%. Pediatricians estimated the incidence of emotional/behavioral problems to be 8.7% while the psychologists estimated the incidence to be 13% to 14.7%. Overall, 51.7% of the children with diagnosed emotional or behavioral problems did not receive counseling, medication or referral from their pediatrician., This study examined how well privatepractice pediatricians can identify emotional/behavioral problems among preschool children. Children aged 2 through 5 (N = 3876) were screened during a visit to 1 of 68 pediatricians who rendered an opinion about the presence of emotional/behavioral problems. Subsequently, children who scored above the 90th percentile for behavioral problems on the Child Behavior Checklist, along with children matched on age, sex, and race who had screened low, were invited for an intensive second-stage evaluation. There were 495 mothers and children who participated in that evaluation, which included a behavioral questionnaire, maternal interview, play observation, and developmental testing. Two PhD-level clinical child psychologists rendered independent opinions about the presence of an emotional/behavioral disorder. The psychologists identified significantly higher rates of problems overall--13.0% when the criterion was independent agreement that the child had an emotional/ behavioral problem and a regular psychiatric diagnosis was assigned, vs 8.7% based on pediatricians' ratings. Prevalence rates based on psychologists' independent ratings were significantly higher than pediatricians' for both sexes, 4- through 5-year-olds, and whites, but not for 2- through 3-year-olds, African-Americans, and all minorities. Prevalence rates based on psychologists' ratings were significantly higher than the pediatricians' for all subgroups when V-code diagnoses were included in the psychologists' ratings. Overall, pediatricians' sensitivity was 20.5%, and specificity was 92.7%. At least 51.7% of the children who had an emotional/behavioral problem based on the psychologist's independent agreement had not received counseling, medication, or a mental health referral from the pediatrician. It is concluded that a substantial number of preschool children with behavior problems in primary care are not being identified or treated. Pediatrics 1993;91:649-655; primary care, pediatric psychopathology, screening, behavior, preschoolers, development.

Atherosclerosis, the build-up of plaque that causes narrowing of the blood vessels supplying the heart, is a process that begins early in childhood and can cause coronary artery disease. High blood cholesterol (hypercholesterolemia), particularly low density lipoproteins (LDLs), contribute to the development of atherosclerosis. High total cholesterol and LDL can run in families; elevated levels can be observed in childhood and throughout adulthood. To establish risk and reduce the incidence of heart disease, families can be tested for elevated blood cholesterol. Children born to parents with high blood cholesterol or coronary artery disease are at risk for having high cholesterol themselves. Many pediatricians selectively screen children with a family history of heart disease and high blood cholesterol. The role of family history in selecting which children should be screened for hypercholesterolemia is unclear. The efficacy of using family history factors as a screening tool for high blood cholesterol was studied in 1,005 randomly selected children between the ages of 2 and 13 years. Coronary health profiles were determined for parents and grandparents. More extensive blood testing was performed on the 274 children with blood cholesterol levels of 175 milligrams/deciliter and above. Of these, 88 children had high LDL levels for their age and sex. Although elevated LDL levels were associated with grandparental histories of coronary artery disease, the test was not sensitive enough to be used as a predictive tool. Family histories did not identify half of the children with high LDL levels, including children with the most severe increases. Selecting children for cholesterol screening based on family history alone is not an effective approach. Although all children with a family history of hypercholesterolemia and coronary artery disease should be screened, the best approach would include testing all children for hypercholesterolemia. (Consumer Summary produced by Reliance Medical Information, Inc.)