Screening for Social-Emotional and Behavior Delays in Early Childhood

I. Introduction. According to the National Survey of Children’s Health, 11.3% of children in the United States are affected by emotional, behavioral, or developmental conditions, based on parental report. Across all ages of childhood, as many as one in five children are estimated to have mental health problems. Social-emotional and behavioral problems that first emerge in the early childhood (by 5 years of age) often persist within early childhood and are predictive of mental health problems in elementary school. However, many young children do not receive needed mental health services. Lack of attention likely prolongs and exacerbates children’s difficulties and contributes to increased parent and family stress. Pediatric clinicians are increasingly essential to the early identification and referral for children with social-emotional/behavioral problems. Clinicians must balance identifying mental health problems with competing medical and developmental demands that are inherent to routine healthcare maintenance. Screening, which relies on the use of an assessment tool, is considered by many to be a necessary supplement to developmental surveillance.

II. Goals and benefits of screening. The general goal of developmental/behavioral screening is to identify children who may be experiencing delays or difficulties in a particular developmental domain (e.g., language, cognition, social-emotional). A primary goal of screening is to identify children from a large pool who may be at elevated risk in a relatively quick and cost-effective manner. Once identified, practitioners employing multigated or multistage screening can follow up with children whose scores fall within the “at-risk” range with a longer measure or clinical interview to obtain more detailed information about the specific nature of the child’s difficulties and to help in referral or treatment planning. Screening is particularly important in early childhood because some young children have limited contact with formal childcare or preschool settings. These children are unlikely to come into contact with childcare or educational professionals who may help to identify delays.

III. Considerations for early childhood

A. Behaviorally specific tools. Screening tools that inquire about specific behaviors help to establish whether the level of behavioral problems reported by a parent is higher than that normally expected for the child’s age. This is especially important for parents of young children, as they often have difficulty determining when difficult child behavior crosses the boundary between normative and atypical and warrants worry or concern. Many parents who report high levels of behavioral problems do not endorse feeling worried or concerned about these issues.
B. Tools that assess both behavioral problems and competencies offer a balanced view not only of problem areas, but also of areas of strength for the child. This information can help to guide decisions about next steps for follow-up assessment and referral.
C. Cognitive and language delays may increase the young child’s risk for social-emotional/behavioral problems. Thus, social-emotional screening should be considered when delays in these other domains are evident.
D. Importance of multiple informants. Young children can behave very differently in different contexts or settings. Screeners that have forms for both parents and childcare/preschool teachers can offer important insight into similarities and dissimilarities in how children behave in the family/home context compared with that in the childcare setting.
E. Access to follow-up care. A common barrier to screening is the limited capacity of the current mental health system to manage referrals for young children. Identifying and building referral relationships with agencies and service providers in the region to facilitate referrals is an important step to support the successful implementation of screening.

IV. Choosing a screening tool. Several screening tools that focus on social-emotional/behavioral problems and are appropriate for use with young children, aged 0-5 years, are presented in Table 13-1. The screening tools presented in this table meet most or all of the following criteria:

Table 13-1. Social-emotional/behavioral problem screeners for early childhood

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