Never too soon:
Identifying social-emotional problems in infants and toddlers

By Jane Squires, PhD, and Robert Nickel, MD

The earlier that social-emotional problems are recognized, the better the outcome is likely to be. Several recent screening tools for children from birth to 3 years can facilitate this process using parent-completed questionnaires that are quick, easy, and economical in office practice.

An estimated 13% of preschool children have mental health problems, and prevalence has increased over the last two decades.^1,2 Prevalence is even higher among preschool children living in an environment of risk, with estimates ranging from 17% to 25%.³ Infants, toddlers, and preschoolers living in poverty—an increasing number over the last decade—have twice the rate of mental health problems of other children.⁴

Although some physicians believe that infants and toddlers are too young to have social and emotional problems, many researchers have concluded that identifying infants and toddlers at risk of a mental health disorder is crucial for improving developmental outcomes.⁵ Early identification is essential for three reasons. First, in terms of brain development, quality early relationships and experiences can positively affect gene function, neural connections, and the organization of the mind, having lifelong positive effects.⁶ Second, once established, social and emotional problems are highly resistant to change.⁷ It is not surprising that a strong relationship exists between childhood social and emotional problems, delinquency, and later criminality.⁷ Third, the costs associated with antisocial and criminal behavior are staggering. Targeted interventions may improve outcomes and save subsequent social costs, such as those incurred in juvenile justice programs.⁸

Primary care physicians are in a unique position to identify social-emotional problems, yet pediatricians and family practitioners underidentify children with such problems.^9,10 Studies also have reported a lower level of recognition of social and emotional problems in preschool children and girls compared with older children and boys.¹¹

This article focuses on identifying infants and toddlers—birth to 3 years of age—with a potential social-emotional problem as part of health promotion in a primary care office. We use "social-emotional" to include behavioral, conduct, psychiatric, psychosocial, and general mental health disorders. We review selected screening tools and make some recommendations, including the use of parent-completed early childhood social-emotional screening tests for children from risk environments or whose caregivers indicate concerns in social-emotional areas.

The goal of the recommended screening process is to promote optimal mental health and development by helping parents to assess their own child's skills. Eliciting information from parents about areas of concern enables physicians to identify problems early and provide appropriate supports to families.

Barriers to identifying problems

Underidentification of infants and toddlers with a mental health problem often occurs because parents have limited opportunities to state their concerns during a well-child visit and are reluctant to share behavioral and mental health concerns with the primary care physician. In one study, 81% of parents said that they believed it is appropriate to discuss four or more of six hypothetical situations with their child's physician, yet only 41% of parents had actually discussed such situations when they occurred.¹² It is estimated that only 24% to 31% of parents express nonmedical concerns to their child's pediatrician.¹³ Time constraints on physicians often prevent them from eliciting concerns from parents and families. When parents do voice concerns, physicians are more likely to identify social-emotional problems in children and make appropriate referrals.^12–14

Other factors contributing to underidentification of problems in infants and toddlers include:^12,14,15

• lack of reimbursement for screening and identification of mental health problems and counseling of families

• need for additional training of primary care health professionals and office staff

• lack of community mental health resources for infants and toddlers and their families.

Table 1 summarizes barriers to early identification.

TABLE 1
Barriers to identifying social-emotional problems

Limited time during well-child visits

Reluctance of families to share concerns

Lack of reimbursement for screening and identification

Need for additional training for physicians and office staff

Limited availability of mental health resources

Potential solutions

Many parents do not feel comfortable voicing their concerns unless the physician initiates a conversation. Parent-completed screening questionnaires provide an optimal structure for parents to identify and focus concerns about their child. Failure to use structured screening tests has been cited specifically as a reason for delayed identification of developmental disorders such as autism in young children.¹⁶ Parent-completed questionnaires not only provide a framework for parents to discuss concerns but also enable the physician to elicit detailed information regarding the child's development. Table 2 summarizes the benefits of parent-completed screening tests.

TABLE 2
Benefits of parent-completed mental health screens

Invite the parent to discuss questions about the child's social and emotional development

Are efficient, requiring limited use of professional time

Review the development of specific competencies as well as behavior concerns

Provide cutoffs at specific ages to identify atypical behavior

Help determine the need for further information and referral

Parent-completed screens offer a partial solution to the lack of reimbursement for screening. They are low-cost because they involve little professional time to score and review. The cost of using the Ages and Stages Questionnaires¹⁷ has been reported to be $8.50 per questionnaire, including postage and professional time.¹⁸ Other solutions to the lack of reimbursement for screening services include using appropriate procedural and diagnostic codes and advocating for improved mental health benefits and reimbursement. These issues are reviewed in the American Academy of Pediatrics' Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version¹⁹ and Bright Futures in Practice: Mental Health.¹⁵

The DSM-PC and Bright Futures offer excellent training materials for physicians and office staff. The DSM-PC outlines a process to follow to determine if a behavioral concern is a developmental variation, a problem, or a disorder; to identify important environmental situations or stressful events; and to classify the severity of the specific behavior concern. Bright Futures offers a variety of tips for the promotion of optimal mental health in children of all ages as well as tools for health-care professionals to use with families, such as age-specific observations of the parent-child interaction and recommendations for interventions for specific disorders. The surveillance process that we recommend is consistent with, and complementary to, both of these resources.

Health promotion activities such as screening for social-emotional problems can be incorporated into a busy primary care practice. The authors of Bright Futures recommend the following strategies to maximize the time for health promotion:^12,20

• have parents complete surveys in the waiting room

• train staff to elicit information from families and provide follow-up

• assist the family in prioritizing needs

• schedule follow-up appointments.

Primary care professionals can use parent-completed screens to initiate a conversation with families, provide a relatively complete review of the child's competencies and potential problems, and help determine whether a particular concern is a developmental variation, problem, or disorder. They can use the materials in DSM-PC and Bright Futures to clarify the area of concern, review contributing factors, and decide next steps.

An additional resource for health-care professionals is the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3).²¹ DC:0-3 was specifically developed to address problems with the use of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)²² in young children. DC:0-3 defines a process for organizing observations and information from other assessments to help with diagnosis and development of a treatment plan with families.

Community-based mental health resources for children and families are limited. Collaborative community-based approaches can help conserve resources and provide more comprehensive services.²³ Primary health-care professionals need to establish partnerships with families and community providers, including early intervention programs, to develop integrated services for young children with social-emotional problems and their families.

Using screening tests in surveillance

To improve the accuracy and efficiency of developmental surveillance, it is important to use formal screening measures in addition to observation and interview.²⁴ Screening tests also need to be repeated over time to improve the effectiveness of the screening process. Having parents complete a simple questionnaire may improve the accuracy of the screening process while empowering them and conserving valuable professional resources.²⁵ Parents may provide information that they would not otherwise share and may provide more complete information with a small investment of professional time.

A formal screening measure should adhere to psychometric standards so that accurate and efficient management decisions are made. In general, the management recommendations presented in DSM-PC are:

• reassurance for a developmental variation

• short-term counseling and follow-up for a problem

• referral for evaluation by a mental health professional for a disorder.

A formal screening test that has established psychometric properties, including a normative sample with cutoffs to clearly identify atypical behavior at specific ages, is essential to help differentiate a developmental variation from a problem or a disorder.

In the past decade, several mental health screening tools have been developed for the birth to 3-year-old population. These tools are broadly based and assess social and emotional behaviors as well as adaptive and play skills.²⁶ Table 3 describes the characteristics of selected social-emotional screening tools, including age range, administration time, number of items, content, administrator, and psychometric data. All the tools described target the birth to 3-year-old age range, assess social or emotional domains, or both, are completed by parents or caregivers, and have acceptable psychometric studies to support their use. (Social-emotional tests with adequate psychometric properties for the 3- to 5-year-old preschool population are reviewed elsewhere.²⁷ They include the Pediatric Symptom Checklist¹ and the Social Skills Rating Scale.²⁸)

TABLE 3
Selected social-emotional screening tools for infants and toddlers

Recommendations

We recommend that all infants and toddlers be assessed at regular intervals with a parent-completed general developmental screen such as the Ages and Stages Questionnaires. We recommend using a social- emotional screening tool when:

• parents express a concern in social, emotional, or behavioral areas

• a general developmental screen indicates potential problems in the personal-social or social-emotional areas

• the physician has a concern about child behavior or parent-child interactions (Table 4).

TABLE 4
Recommendations for using social-emotional screens

Use a behavioral screen when

Parents have a concern

Child exhibits delay on personal-social section of the general screen or physician notes concern about child's behavior or parent-child interaction

If screen does not identify potential problem

Review issues at next well-child visit, or sooner, based on family choice

If screen identifies potential problem

Obtain further information to clarify management issues

Use in-depth, parent-completed tool (e.g., Child Behavior Checklist)

Observe parent-child interaction

Review situational factors (DSM-PC)

Request information from day-care and preschool providers

or

Refer to mental health provider

We also recommend that physicians follow the guidelines for mental health promotion described in Bright Futures.

For children from birth to 3 years of age, we specifically recommend using the Brief Infant-Toddler Social Emotional Assessment (BITSEA)²⁹ or the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE)³⁰ because these instruments are broad-based, meet established psychometric standards, and are easy to use in office settings. Additional tools for 2- to 3-year-olds include the Devereux Early Childhood Assessment (DECA)³¹ and the Eyberg Child Behavior Inventory.³² All these questionnaires are brief, easily scored, and can be completed in the waiting room before the examination or mailed to parents before an appointment. Office assistants can score the questionnaires before the examination in a minute or two.

If a parent-completed social-emotional tool elicits concerns, follow-up can include in-office administration of an in-depth social-emotional assessment, such as the Child Behavior Checklist³³ or Infant Toddler Social Emotional Assessment,³⁴ or referral to an early intervention team or mental health professional for further evaluation and services. In-depth assessments, described in Table 5, provide more complete information on social- emotional competence and can help with referral decisions. Additional information such as observation of the parent-child interaction, review of the situational factors listed in the DSM-PC, and information from day-care and preschool providers also may help determine an appropriate management strategy.

TABLE 5
In-depth social-emotional assessment tools for infants and toddlers

Achenbach T, Rescorla L

2000

Child Behavior Checklist
1 South Prospect
St. Burlington, VT 05401

The earlier the better

Because of the complexity of social-emotional issues and the frequent presence of a constellation of family issues, it is important for the physician to have a menu of options for families, including mental health, family support, and special education services. Physicians need to keep a current list of community referral sources, including telephone numbers, insurance information, and approximate cost for services such as counseling and substance abuse prevention. Including a pediatric mental health provider either near or within a medical clinic is one strategy that some pediatricians have pursued in order to facilitate consultation and referral to mental health services.²⁰

As recommended, infants and toddlers should be assessed using a social-emotional screening test when parents or providers have concerns or when a general developmental assessment indicates problems in social-emotional skills. Using a parent-completed screening tool provides a forum for the parents to discuss their concerns and provides the physician with in-depth developmental information on the child.

REFERENCES

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15. Palfrey J: Bright Futures in Practice: Mental Health. Washington, D.C., National Center for Education in Maternal and Child Health, 2002

16. Filipek PA, Accardo PJ, Ashwal S, et al: Practice parameter: Screening and diagnosis of autism: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology 2000;55(4):468

17. Bricker D, Squires J, Mounts, L: Ages and Stages Questionnaires: A Parent-Completed, Child Monitoring System. Baltimore, Paul Brookes, 1995

18. Chan B, Taylor N: The follow along program cost analysis in southwest Minnesota. Infant and Young Child 1998;10(4):71

19. Wolraich ML, Felice ME, Drotar D: The Classification of Child and Adolescent Mental Diagnoses in Primary Care. Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. Elk Grove Village, Ill., American Academy of Pediatrics, 1996

20. Benjamin JT, Cimino SA, Hafler JP, et al: The office visit: A time to promote health—but how? Contemporary Pediatrics 2000;19(2):89

21. Zero to Three: Diagnostic Classification: 0-3, Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Arlington, Va., National Center for Clinical Infant Programs, 1995

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29. Carter A, Briggs-Gowan, M: Brief Infant/Toddler Social Emotional Assessment (BITSEA). Available from authors by e-mail: ITSEA@yale.edu. Accessed September 23, 2001

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32. Eyberg S, Pincus D: Eyberg Child Behavior Inventory (ECBI). Odessa, Fla., Psychological Assessment Resource, 1999

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The earlier that social-emotional problems are recognized, the better the outcome is likely to be. Several recent screening tools for children from birth to 3 years can facilitate this process using parent-completed questionnaires that are quick, easy, and economical in office practice.

DR. SQUIRES is associate professor, Early Intervention Program, College of Education, University of Oregon, Eugene. She is a developer of the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE).

DR. NICKEL is associate professor, Regional Services Center, Child Development and Rehabilitation Center, Department of Pediatrics, Oregon Health Sciences University, Eugene. He has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

KEY POINTS

Early screening for social-emotional problems

• Several valid, reliable screening tools designed for infants and toddlers can be used in the pediatrician's office to help identify behavioral problems early.

• Helping parents find services when their children are young may help prevent a myriad of problems later in childhood—including antisocial, violent, and destructive behaviors.³⁵

• Early intervention for social-emotional disturbances will save families and society countless dollars and promote more positive developmental outcomes for youngsters with social-emotional problems.

Jane Squires, Robert Nickel. Never too soon: Identifying social-emotional problems in infants and toddlers.

Contemporary Pediatrics

2003;3:117.