Measuring behaviour in children with high cholesterol levels
CMAJ 1997;157:372
See response from: E. Rosenberg
The article "Cholesterol screening of children at high risk: behavioural and psychological effects" (CMAJ 1997;156:489-96 [abstract / résumé]), by Dr. Ellen Rosenberg and associates, adds to the growing literature on the harms of preventive medicine.
Although the authors are cautious with their conclusions, we believe that several methodologic problems limit their ability to draw the conclusions that they did. The first is the timing of administration of the Child Behavior Checklist (CBCL). The authors did not provide the baseline measurements; furthermore, the CBCL protocol requests that parents rate behaviour during the 6 months preceding the test. Thus, the CBCL scores at 1 month may reflect behaviour during the 6 months preceding the test, before the diagnosis of hyperlipidemia. Likewise, the 12-month assessment may reflect the immediate postdiagnosis scores. The authors omitted the competence section of the CBCL, which states that the problem section "measures the disturbances most relevant to [their] subjects." Data obtained from the competence section provide valuable information and may be equally important in evaluating behavioural problems. Indeed, the authors of the CBCL have determined that inclusion of competence scores can reduce the chance of misclassifying children's behaviour as being in the "clinical range."1 Moreover, examining the child's abilities in sports and friendships taps important aspects of a child's behaviour that may be affected by a chronic illness.
The authors report no differences between scores on any of their outcome measures, but then state that children in the case group were "much more likely" to have behavioural disturbances, based on the proportions of the group with high CBCL scores. This conclusion is flawed for 2 reasons. First, child behaviour is a continuum. Making categorical distinctions on the basis of the CBCL score is less reliable for children who score in the "borderline" category (around 62), and there is clearly an advantage to comparing continuous quantitative scores.1 Second, the small sample size complicates the interpretation of the differences in proportions of patients who had "high" scores. We carried out a chi2 analysis of the proportions of children with high scores at any time; it did not show a statistical difference between the groups.
Behavioural scores in children result from a myriad of personal, social, cognitive and situational variables.2 The limitations of this study considerably hinder the strength of the conclusions concerning the behavioural effects of lipid screening.
David P. Joyce, MD
Resident
St. Michael's Hospital
Toronto, Ont.
Marjolaine M. Limbos, MSW
Department of Human Development and Applied Psychology
Ontario Institute for Studies in Education
Toronto, Ont.
References
- Achenbach TM. Manual for the Child Behavior Checklist/4-18 and 1991 profile. Burlington (VT): University of Vermont Department of Psychiatry, 1983.
- Sattler JM. Assessment of children. 3rd ed. San Diego (CA): Jerome M. Sattler; 1992.
 |
Send a letter to the editor responding to this letter
Envoyez une lettre à la rédaction au sujet de cette lettre |
Letters