Eur Child Adolesc Psychiatry DOI 10.1007/s00787-014-0575-2
ORIGINAL CONTRIBUTION
A prospective study of behavioral and emotional symptoms in preschoolers Annette M. Klein • Yvonne Otto • Sandra Fuchs Ina Reibiger • Kai von Klitzing
•
Received: 28 February 2014 / Accepted: 5 June 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract A substantial number of preschool children exhibit psychological symptoms that have an impact on their own and their families’ lives. The aim of the current study was to investigate the prevalence, stability and increase/decrease in emotional and behavioral symptoms and the resultant impairment at two assessment points at preschool age. The sample consisted of 1,034 children drawn from the general population with a mean age of 51 months at t1 and 72 months at t2. Parents completed the Strengths and Difficulties Questionnaire extended version (Goodman, J Child Psychol Psychiatry 38(5):581–586, 1997; Goodman, J Child Psychol Psychiatry 40(5):791– 799, 1999). At t1, 6.9 % of the preschoolers had a total difficulties and 6.8 % a total impact score within the abnormal range. At t2, these scores were 5.7 and 6.2 %, respectively. We found moderate stability of symptoms. From t1 to t2, emotional symptoms and prosocial behavior significantly increased, while hyperactivity, conduct problems, peer problems and total difficulties decreased. The mean total impact score did not change. Boys showed higher levels of symptoms (except emotional symptoms) and impact, and lower prosocial behavior, than girls. Moreover, there was a significant time 9 gender interaction, with girls showing a larger decrease in hyperactivity/ inattention and in total difficulties than boys. The stepwise multiple regression analysis revealed that the total impact A. M. Klein (&) Y. Otto S. Fuchs K. von Klitzing Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University of Leipzig, Liebigstr. 20a, 04103 Leipzig, Germany e-mail: [email protected] I. Reibiger Health Department at the Municipal Authority in Leipzig, Leipzig, Germany
score at baseline, male gender, conduct problems, hyperactivity and peer problems significantly contributed to the explained variance of the total impact score at follow-up. This is one of very few studies to examine the stability and change of psychological symptoms in a large community sample of preschoolers, assessed twice during preschool age. Keywords Child mental health Emotional symptoms Behavioral symptoms Stability Preschool age
Introduction A substantial number of preschool-age children exhibit emotional symptoms, conduct problems or symptoms of hyperactivity, which have an impact on their own and their families’ lives. The prevalence rates reported for these symptoms at preschool age differ markedly, and especially between countries, ranging from 4.6 and 7.1 % in Denmark [1] and Norway [2], respectively, to 27.4 % (or 22.5 % when excluding specific phobia) in preschoolers in the USA [3]. Studies in Germany showed prevalence rates of mental health problems of 5.3 % in 3- to 6-year-olds [4] and 12.4 % in 6-year-olds [5]. Research has shown that childhood psychopathology must be taken seriously, as emotional symptoms, conduct problems or hyperactivity are unlikely to be transient and, especially if they remain stable, can impair the child’s functioning and development [6]. A number of studies have investigated the stability of psychological symptoms in preschool and school-age children. Edwards et al. [7] found a remarkably high stability of anxiety symptoms (r = 0.75) in 3- to 5-year-old children over 12 months. But several studies suggest that externalizing problems show more
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stability and persistence than internalizing problems [6, 8– 11]. Verhulst and Van der Ende [12] assessed parentreported mental health of children aged 4–16 five times at 2-year intervals. Stability coefficients decreased with time, but even over a period of 8 years, there was a considerable stability, with r = 0.50 for externalizing and r = 0.39 for internalizing scores. The 2-year correlation coefficients for attention problems, internalizing and externalizing scores as well as the total problem score were greater than r = 0.60. Ford and colleagues [13] also found marked stability of mental health problems over 3 years with r = 0.71 in children aged 5–18 years. By using a categorical approach, Lavigne and colleagues [9] examined the stability of psychiatric disorders in children aged 2–5 years at the first wave of data collection. 344 families participated again 42 through 48 months later. Intraclass correlations were 0.497 for emotional disorders and 0.718 for disruptive disorders, indicating moderate stability. Bufferd and colleagues [14] examined the continuity of specific psychiatric disorders in a community sample of preschoolers (N = 462) from ages 3 to 6. They found, that the three-month rates of disorders were relatively stable. Children meeting criteria for any diagnosis at age 3 were nearly five times as likely as the others to meet criteria for a diagnosis at age 6. Moreover, they found both homotypic (e.g., Anxiety, ADHD) and heterotypic continuity (e.g., between depression and anxiety). Overall, studies investigating stability of emotional and behavioral symptoms or psychiatric disorders in community samples of exclusively preschool children are rare. In contrast, there is good knowledge of gender differences in emotional and behavioral symptoms in preschool and early school age. Many studies found gender differences in externalizing, but not internalizing symptoms, with boys showing more behavior problems and/or hyperactivity [1, 7, 10, 15–18]. Parents often also report a higher level of overall mental health problems for boys in preschool and school age than for girls [1, 18–20]. Our own baseline study with N = 1,738 children between the ages of 3 and 5 years showed that boys had higher mean scores than girls on the subscales for conduct problems, hyperactivity and peer problems, and lower scores on the scale measuring prosocial behavior. Moreover, boys showed a higher level of overall mental health problems and more impairment due to those problems than girls. Boys and girls did not differ in emotional symptoms [21, 22]. In order to investigate the course of symptoms over time and the influence of gender on the course, longitudinal studies with several assessment points are necessary. There have been only a few longitudinal studies of community samples that also included preschoolers. In the study by Keiley and colleagues [23] in which they assessed 405 children annually starting in kindergarten (age 5 years) up
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to seventh grade, mothers reported decreasing externalizing behavior and stable internalizing problems. Bongers and colleagues [15] used a longitudinal multiple birth-cohort design with 2,076 children aged 4–18 years selected from the general population to identify normative developmental trajectories of mental health problems at five assessment points at 2-year intervals. They identified specific trajectories, mostly differing for girls and boys. They found that for internalizing problems, there were no gender differences in childhood, but there was a gender effect on the slope of the trajectory, with girls showing a steeper increase in internalizing problems than boys. Both boys and girls showed normative developmental trajectories of externalizing problems that decreased with age, with boys showing more problems than girls at all ages and a steeper decrease in symptoms than girls. Attention problems showed a linear and quadratic change over time (increasing until age 11 and declining thereafter) with no gender effect on the slope. However, the initial value differed significantly between boys and girls, with boys showing higher attention problems at all ages. Using a similar approach, Stanger and colleagues [24] also reported declining aggressive and delinquent behavior in children initially assessed at ages 4–10 years, again with higher scores for boys than girls. In their longitudinal study with two assessment points, Beyer and colleagues [20] assessed 814 children prior to school entry (t1) and 4 years afterward and found increasing internalizing symptoms and attention problems while externalizing symptoms decreased over time. A cross-sectional study by van Leeuwen et al. [18] revealed higher parent-reported total difficulties scores, emotional symptoms and hyperactivity in children in the age group 6–7 years compared with 4- to 5-year-olds. The crosssectional study of a German representative sample by Ho¨lling and colleagues [16] showed no differences between the age groups 3–6 and 7–10 years for hyperactivity; only 14- to 17-year-olds had a lower mean score. In contrast, the youngest age group 3–6 years showed significantly higher conduct problems than the other age groups. Epidemiological studies predominantly focus on emotional and behavioral symptoms. However, even children with high levels of symptoms rarely receive professional help, sometimes because the families themselves are not concerned about the symptoms [25, 26]. Factors influencing the help-seeking behavior of families include whether parents or teachers perceive a problem and whether symptoms impose a burden on parents, teachers or others [27]. The latter is a powerful predictor of whether or not the child will be referred to professionals [28]. Therefore, it seems highly relevant to assess not only the children’s symptoms, but also whether parents perceive them as problematic, and if so to
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ask about the resulting distress and social impairment for the child. Moreover, it is of interest to identify which symptoms are highly associated with impairment longitudinally as this might be useful in identifying children at risk for chronic mental health problems. Our own baseline study with N = 1,738 children between the ages of 3 and 5 years showed that cross sectionally impairment was predicted by emotional symptoms, conduct problems, hyperactivity and peer problems, with emotional symptoms contributing the most to the explained variance, followed by hyperactivity and conduct problems [21]. Overall, empirical data on the stability and change of emotional and behavioral symptoms and impairment during the preschool years are scarce. Existing longitudinal studies that include preschoolers [9, 14, 15, 20, 23, 24] mostly have a second assessment at school age. In this study, we therefore aimed to investigate the prevalence and stability of emotional and behavioral symptoms and resultant impairment in preschool children aged 3–5 years at the baseline and 5–6 years at the followup assessment. Based on the literature, we expected to find moderate stability of emotional and behavioral symptoms. Second, we investigated whether symptom scores increased or decreased over time, as well as noting gender differences and possible interactions of gender with change over time. In line with the findings reported above, we expected to see increasing emotional symptoms and hyperactivity and decreasing conduct problems. Moreover, we expected gender differences in externalizing but not internalizing symptoms and interactions of gender with change over time. Third, we wanted to explore which symptoms predict later impairment as this could help to identify which children with mental health problems need early intervention.
Method Study design and sample The present study was designed prospectively to explore stability and change in emotional and behavioral symptoms in children drawn from the general population of preschool children in Leipzig, a city with a population of about 520,0001 residents in the eastern part of Germany. The Health Department of this city conducts pediatric and developmental assessments twice during preschool age: first, an optional assessment at the age of 3–5 years and a second obligatory assessment at the age of 5–6 years. In
the latter assessment, school readiness is tested. Parents of children born mainly between July 1, 2005, and June 30, 2006, were invited at these two assessment points to take part in the study and asked to complete a short questionnaire. Participation in the study was voluntary, and parents gave informed consent prior to their inclusion in the study. The study was approved by the appropriate ethics committee. All families received a feedback letter describing their child’s mental health. t1 (baseline) measurements took place between August 2009 and October 2010. Parents received the letter with the invitation to the study via their kindergartens. Of the total number of 3,690 families invited, 1,744 families (47.3 %) returned the questionnaire. Due to missing birth dates, six (0.4 %) subjects had to be excluded. Thus, the baseline sample consisted of 1,738 children, 840 girls (48.4 %) and 898 boys (51.6 %) between the ages of 37 and 63 months (mean age 51 months, SD = 5.2). Table 1 shows the socio-demographic characteristics of the baseline sample. The educational level of parents was found to be representative for the population of parents in the city2 based on data of the State Office of Statistics of Saxony. Of this sample, 94.2 % (N = 1,637) gave contact information (e.g., name of child) and birth date necessary to identify the child at follow-up. At t2 (follow-up), parents had an appointment at the Health Department where the school readiness test of their child took place. There they received a letter with the invitation to take part in our study. Parents were informed that we were interested in the further development of their child and asked to complete the questionnaire and give information (name and birth date) to allow identification of the child. t2 took place between October 2011 and June 2012. Of the total number of 4,299 families invited, 2,626 (61.1 %) filled in the questionnaire. Thus, the t2 sample consisted of 2,626 children, 1,274 girls (48.5 %) and 1,349 boys [51.4 %; N = 3 (0.1 %) missing information on gender] between the ages of 54 and 89 months (mean age 72 months, SD = 4.4). Of these samples, 1,034 families took part at both assessment points and could be clearly identified (63.16 % of the baseline sample with contact details). This sample consisted of 517 girls and 517 boys (each 50.0 %) with a mean age of 51 months (range 37–62 months, SD = 5.2) at t1 and 72 months (range 63–82 months, SD = 3.8) at t2. The mean time between both assessment points was 21 months (range 11–31 months, SD = 4.2). The questionnaire was mainly completed by mothers (t1 83.4 %, t2 82.9 %) and in smaller proportions by fathers (t1 6.0 %, t2 14.4 %), by both parents together (t1 10.1 %, t2 1.6 %) or by other
1
Number of residents 31.12.2012, Statistisches Landesamt des Freistaates Sachsen, http://statistik.leipzig.de/statcity/table.aspx?cat= 2&rub=1&per=q (7.5.2014).
2
Statistisches Landesamt des Freistaates Sachsen, Kamenz, 2014.
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Eur Child Adolesc Psychiatry Table 1 Socio-demographics of the t1 baseline sample (N = 1,738) and the sample taking part at t1 and t2 (N = 1,034) N = 1,738
N = 1,034
At time of data collection t1
51 months (range 37–63; SD = 5.2)
51 months (range 37–62; SD = 5.2)
At time of data collection t2
–
72 months (range 63–82; SD = 3.8)
Boys
898 (51.6)
517 (50.0)
Girls
840 (48.4)
517 (50.0)
Mean age
Gender (%)
Educational level at t1, mother (%) Low school diploma
210 (12.1)
112 (10.8)
High school diploma
875 (50.3)
551 (53.3)
University degree
641 (36.9)
366 (35.4)
Missing
12 (0.7)
5 (0.5)
Educational level at t1, father (%) Low school diploma
199 (11.4)
123 (11.9)
High school diploma
792 (45.6)
472 (45.6)
University degree
649 (37.3)
388 (37.5)
Missing
98 (5.6)
51 (4.9)
Employed at t1, mother (%) Yes
1,335 (76.8)
813 (78.6)
No
386 (22.2)
216 (20.9)
Missing
17 (1.0)
5 (0.5)
Employed at t1, father (%) Yes
1,487 (85.6)
900 (87.0)
No
143 (8.2)
80 (7.7)
Missing
108 (6.2)
54 (5.2)
caregivers (t1 0.5 %, t2 1.1 %). For the demographic features of the sample, see Table 1. These 1,034 participants identified at both assessment points did not differ significantly from the baseline sample of 1,738 families in children’s age and gender, parents’ educational level and vocational situation, or psychological symptoms (all p [ 0.18). Instruments At both assessment points, parents gave basic demographic information about the child (birth date, gender), their own educational level (highest level reached at school/university) and employment situation and completed the German parentrated form of the Strengths and Difficulties Questionnaire extended version (SDQ P4-16) [27, 29, 30]. The SDQ is an internationally used and well-validated 25-item screening instrument that consists of positive and negative attributes of
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the child, which are rated as being not true (0), somewhat true (1) or certainly true (2). The SDQ consists of five subscales, each comprising five items, thus yielding scores between 0 and 10. Four of the SDQ subscales represent symptom scores: emotional symptoms, conduct problems, hyperactivity, and peer problems, with higher scores indicating more problems. These four subscales are summed up to obtain a total difficulties score ranging from 0 to 40. The fifth subscale assesses prosocial behavior, with higher scores indicating more positive behavior. The total difficulties score and scores of the subscales are classified as normal, borderline or abnormal based on the German normative sample (N = 930 children between 6 and 16 years of age) and its derived cut-off scores published by Woerner and colleagues [31]. A few SDQ questions were modified, substituting ‘‘kindergarten’’ for ‘‘school’’ and ‘‘preschool teacher’’ instead of ‘‘teacher’’ as all children were preschoolers. Using the additional impact supplement [27], the parents indicated whether in general they perceived that their child has difficulties in one or more of these areas: emotions, concentration, behavior or relationships. If parents reported a problem, they were asked to answer additional questions about whether these difficulties upset or distress their child and whether they interfere with their child’s everyday life in different areas: home life, friendships, learning and leisure activities. Following the recommendations of Goodman [27], the original 4-point scale (0 = not at all, 1 = only a little distress/impairment, 2 = quite a lot, 3 = a great deal) was converted to a 3-point scale (0 = not at all/only a little distress/impairment, 1 = quite a lot, 2 = a great deal), aggregating ‘‘not at all’’ and ‘‘only a little’’ distress or impairment as these were considered clinically irrelevant. All ratings combined formed the total impact score as a dimensional score. The SDQ is well received by parents as it is brief and also because it addresses children’s strengths. Several studies have established the validity and reliability of the SDQ parent-rated form [32], including the German version [33, 34]. Moreover, a review of 48 studies [35] confirmed that the SDQ is a psychometrically sound measure for assessing children’s mental health problems. Although Cronbach’s a coefficients are usually found to be acceptable, another indicator of reliability, McDonald’s x has been found to be substantially higher [36]. In our t1 sample of 3- to 5-yearolds (N = 1,738), we found moderate Cronbach’s a coefficients for all subscales and the total difficulties score (a = 0.58–0.79); for details see Klein et al. [22]. Statistical analysis Data handling and all statistical analyses were carried out using IBM SPSS Statistics (Statistical Package for the Social Sciences, release 20).
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We calculated intraclass correlation coefficients (twoway mixed model, type absolute agreement) to assess stability of symptoms. We also conducted a mixed-design MANOVA, with assessment time (t1–t2) as within-subjects factor and child gender as between-subjects factor, and the SDQ scales as dependent variables followed by univariate analyses. Finally, we employed a stepwise multiple regression analysis.
Results Frequencies of symptoms/impairment in abnormal range at baseline (t1) and follow-up (t2) At t1, between 3.2 and 11.4 % of the preschoolers had symptoms classified as abnormal, and 2.1 % had abnormally low prosocial behavior. 6.9 % had a total difficulties and 6.8 % a total impact score in the abnormal range. At t2, between 2.9 and 7.1 % had symptoms classified as abnormal, while 1.7 % showed prosocial behavior in the abnormal range. 5.7 % had a total difficulties and 6.2 % a total impact score in the abnormal range. For all frequencies and percentages, see Table 2. Stability of symptoms and impact In order to assess stability of symptoms, we calculated intraclass correlation coefficients (ICC) for all subscales, the total difficulties score and the total impact score. We found a moderate stability of symptoms, with the lowest ICC for prosocial behavior and the highest for hyperactivity; for all ICCs, see Table 3. The stability of the total difficulties score was higher than the stability of the total impact score. Moreover, we wanted to rule out that the stability estimates are spurious associations due to confounding with maternal education. To assess the influence of maternal education on stability of symptoms, we computed Pearson correlations for symptoms t1–t2 with and without
Table 2 Frequencies (percentage) of symptoms/impairment in abnormal range at baseline (t1) and follow-up (t2) (N = 1,034)
controlling for maternal education of the mother at t1 (partial correlations). The values of the Pearson correlations were highly similar to those of the ICCs and were only minimally reduced (reduction in r = 0.01–0.03) when controlling for education of the mother. Change over time, gender effects and time 9 gender interaction The mixed-design MANOVA on all subscales, the total difficulties score and total impact score with assessment time (t1–t2) as within-subjects factor and child gender as between-subjects factor revealed main effects of assessment time, F(6, 1,005) = 38.44, p \ 0.001, g2p = 0.19, and of gender, F(6, 1,005) = 10.50, p \ 0.001, g2p = 0.06. The interaction of assessment time 9 gender was not significant: F(6, 1,005) = 1.39, p = 0.21, g2p = 0.008. Univariate analyses showed that from t1 to t2, emotional symptoms and prosocial behavior significantly increased, while hyperactivity, conduct problems, peer problems and total difficulties significantly decreased. The mean total impact score did not change (for M, F, p and g2p see Table 4). Effect sizes were mostly small, except for hyperactivity (moderate) and prosocial behavior (moderate to large). Boys had significantly higher total difficulties and impact scores and also showed higher levels of conduct problems, hyperactivity and peer problems than girls. Girls on the other hand showed significantly higher prosocial behavior levels than boys. However, the effect sizes of the gender differences were small. There were no significant gender differences in emotional symptoms (for M, F, p and g2p see Table 5). The univariate analyses revealed significant interactions between assessment time 9 gender for hyperactivity, F(1, 1,010) = 4.23, p \ 0.05, g2p = 0.004, and the total difficulties score, F(1, 1010) = 4.71, p \ 0.05, g2p = 0.005, Table 3 Intraclass correlation coefficients for the SDQ t1–t2 (N = 1,034) SDQ
ICC
95 % CI Lower
Upper
t1, N (%)
t2, N (%) Emotional symptoms
0.47***
0.42
0.52
Emotional symptoms
60 (5.8)
70 (6.8)
Conduct problems
0.52***
0.47
0.57
Conduct problems
55 (5.3)
40 (3.9)
Hyperactivity
0.66***
0.60
0.71
Hyperactivity
118 (11.4)
73 (7.1)
Peer problems
0.45***
0.40
0.50
Peer problems
33 (3.2)
30 (2.9)
Prosocial behavior
0.43***
0.33
0.52
Prosocial behavior
22 (2.1)
18 (1.7)
Total difficulties score
0.63***
0.58
0.67
Total difficulties score
71 (6.9)
59 (5.7)
Total impact score
0.45***
0.40
0.50
Total impact score
70 (6.8)
63 (6.2)
*** p B 0.001
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Eur Child Adolesc Psychiatry Table 4 Scale means (SD) at baseline (t1) and follow-up (t2) (N = 1,034) t1, M (SD)
t2, M (SD)
Univariate tests g2p
F Emotional symptoms
1.58 (1.62)
1.69 (1.70)
4.38*
0.004
Conduct problems
1.75 (1.50)
1.42 (1.47)
52.39***
0.049
Hyperactivity
3.44 (2.34)
2.93 (2.25)
78.28***
0.072
Peer problems
1.09 (1.43)
0.93 (1.34)
12.99***
0.013
Prosocial behavior
7.85 (1.59)
8.46 (1.56)
142.32***
0.124
Total difficulties score
7.86 (4.67)
6.97 (4.83)
49.34***
0.047
Total impact score
0.26 (0.76)
0.24 (0.83)
0.951
0.001
MANOVA univariate tests, two-tailed; df = 1, 1,010 * p \ 0.05, ** p \ 0.01, *** p \ 0.001
Table 5 Scale means (SD) for girls and boys (N = 1,034)
Emotional symptoms t1 Emotional symptoms t2 Conduct problems t1 Conduct problems t2 Hyperactivity t1 Hyperactivity t2 Peer problems t1 Peer problems t2 Prosocial behavior t1 Prosocial behavior t2 Total difficulties score t1 Total difficulties score t2 Total impact score t1 Total impact score t2
Boys (N = 517), M (SD)
Girls (N = 517), M (SD)
1.50 1.71 1.85 1.58 3.65 3.25 1.23 1.08 7.59 8.16 8.24 7.62 0.30 0.33
1.65 1.67 1.64 1.27 3.24 2.61 0.95 0.78 8.11 8.76 7.48 6.32 0.23 0.15
(1.59) (1.74) (1.54) (1.54) (2.29) (2.32) (1.52) (1.44) (1.61) (1.65) (4.66) (5.16) (0.81) (0.93)
(1.64) (1.66) (1.44) (1.39) (2.37) (2.14) (1.31) (1.20) (1.53) (1.41) (4.66) (4.39) (0.70) (0.71)
Univariate tests F
g2p
0.33
0.000
10.40**
0.010
16.24***
0.016
15.28***
0.015
44.87***
0.043
14.61***
0.014
8.62**
0.008
MANOVA univariate tests, two-tailed; df = 1, 1,010 * p \ 0.05, ** p \ 0.01, *** p \ 0.001
with girls showing a greater decrease in hyperactivity and total difficulties than boys. Additional analyses showed that the decrease in hyperactivity and total difficulties was significant for both girls [(hyperactivity: F(1, 507) = 58.07, p \ 0.001, g2p = 0.103; total difficulties score: F(1, 507) = 45.46, p \ 0.001,
g2p
= 0.082)] and boys [(hyperac-
tivity: F(1, 503) = 23.63, p \ 0.001, g2p = 0.045; total difficulties score: F(1, 503) = 11.00, p \ 0.001, g2p = 0.021)]. Furthermore, there was a marginal significant interaction between assessment time 9 gender for the total impact score, F(1, 1,010) = 3.56, p = 0.06, g2p = 0.004. Additional analyses revealed that for boys, there was no significant change, F(1, 503) = 0.35, p = 0.55, g2p = 0.001,
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whereas girls showed a significant decrease in the total impact score, F(1, 507) = 4.98, p = 0.03, g2p = 0.010. The interaction of assessment time 9 gender for emotional symptoms also had a tendency toward significance, F(1, 1,010) = 3.23, p = 0.072, g2p = 0.003, with boys showing a significant increase in symptoms, F(1, 503) = 7.57, p = 0.006, g2p = 0.015, while girls showed no change in emotional symptoms, F(1, 507) = 0.43, p = 0.84, g2p = 0.000. Prediction of total impact score at t2 We used a stepwise multiple regression analysis with two steps in order to evaluate the predictive value of the total impact score at t1 (step 1), as well as gender, symptoms and prosocial behavior at t1 (step 2) in explaining the variance of the total impact score at t2. As explained above, the total impact score includes whether families perceive problems and whether symptoms impose a burden on the child both of which are factors influencing the helpseeking behavior. In step 1, the total impact score at t1 was included and explained 20.5 % of the variance of the total impact score at t2 (R2 = 0.205). In step 2, we entered gender, symptoms and prosocial behavior (forced entry) in order to evaluate their predictive value that goes beyond the total impact score at t1. There was a small but highly significant change of the explained variance (R2 = 0.243, DR2 = 0.038, p \ 0.001). Besides the total impact score at t1 (male) gender, conduct problems, hyperactivity and peer problems but not emotional symptoms or prosocial behavior significantly contributed to the explained variance of the total impact score at t2. The total impact score at t1 had the highest beta value (b = 0.36) followed by hyperactivity and peer problems (both b = 0.11). All standardized and non-standardized beta coefficients are listed in Table 6.
Discussion In this study, 6.9 % of the 3- to 5-year-old preschoolers showed total difficulties scores in the abnormal range as rated by their parents, while 6.8 % of the children were rated as impaired by their difficulties. At the follow-up assessment at the age of 5–6 years these rates were 5.7 and 6.2 %, respectively. This is comparable with the prevalence rates reported previously for German preschoolers [4]. The stability of emotional and behavioral symptoms over 21 months was moderate, with the highest stability found for symptoms of hyperactivity and total difficulties
Eur Child Adolesc Psychiatry Table 6 Stepwise multiple regression analysis for prediction of the total impact score t2 from total impact score t1 (step 1) and gender, symptoms and prosocial behavior t1 (step 2) B
SE B
b
Step 1 Constant Total impact score t1 Step 2 Constant
0.11
0.03
0.49
0.03
-0.38
0.15
0.45***
Total impact score t1
0.40
0.04
0.36***
Gender (0 = girls, 1 = boys)
0.11
0.05
0.07*
Emotional symptoms t1
-0.01
0.02
Conduct problems t1
0.05
0.02
-0.02 0.09*
Hyperactivity t1
0.04
0.01
0.11**
Peer problems t1
0.06
0.02
0.11***
Prosocial behavior t1
0.03
0.02
0.05
R2 = 0.205 for step 1, R2 = 0.243 for step 2, DR2 = 0.038, p \ 0.001 * p \ 0.05, ** p \ 0.01, *** p \ 0.001
(ICCs [0.60). The parent-reported impairment was less stable. Emotional symptoms and conduct problems both showed moderate and almost equal stability, with somewhat higher stability reported for conduct problems. This result is broadly in accordance with other studies reporting higher stability for externalizing than internalizing symptoms [6, 8–11]. Moreover, we could rule out that the stability estimates are spurious associations due to confounding with maternal education. Parents reported increasing emotional symptoms and prosocial behavior and decreasing hyperactivity, conduct problems, peer problems and total difficulties between the two assessment time points. The mean total impact score did not change. Most of these findings are in line with the literature and therefore with our expectations. Previous longitudinal studies investigating preschoolers and school children also found increasing internalizing symptoms [15, 20] and decreasing externalizing symptoms over time [15, 20, 23, 24]. Even if the effect sizes of the changes in emotional symptoms and conduct problems were only small, these would be clinically significant on the long run if the development described continued. Moreover, the increase in prosocial behavior was substantial and could be a potential protective factor for the further development of the children. The decrease in symptoms of hyperactivity was unexpected, since several longitudinal studies have revealed increasing hyperactivity until about the end of primary school [15, 20]. The cross-sectional study by van Leeuwen et al. [18] also reported higher hyperactivity in 6- to 7-yearolds than in 4- to 5-year-old children. In contrast, the crosssectional study by Ho¨lling and colleagues [16] showed no
differences in hyperactivity between the age groups 3–6 and 7–10 years. The decrease found in our study might result from a parental overestimation of hyperactivity at the baseline assessment. The SDQ scale describes hyperactive behavior as ‘‘restless, overactive, cannot stay still for long’’, ‘‘easily distracted, concentration wanders’’ and ‘‘thinks things out before acting’’ (not true), which is quite typical behavior for 3–5 year olds. At t1 the mean score was 3.44, somewhat higher than the score of 3.2 in the German representative sample of 3- to 6-year-olds [16]. However, as the SDQ is widely used, we cannot really explain why parents reported a decrease in hyperactivity. Further longitudinal assessment in order to explore trajectories would be very interesting. As we had expected, parent reports in almost all subscales, the total difficulties score and the total impact score differed for boys and for girls. Boys had significantly higher total difficulties and total impact scores and showed higher levels of conduct problems, hyperactivity and peer problems and lower prosocial behavior than girls, albeit with small effect sizes. Only for emotional symptoms were there no significant gender differences. These findings are in accordance with earlier studies investigating preschoolers or primary school children, which typically report higher externalizing problems and overall mental health problems in boys than in girls, but with no gender differences for internalizing problems [1, 7, 10, 15–18]. Furthermore, we found significant interactions of assessment time by gender, although with small effect sizes. Girls showed a larger decrease in hyperactivity and total difficulties than boys. Also, there were marginal significant interactions for emotional symptoms—no change in girls but a significant increase in symptoms for boys— and the total impact score, with a decrease for girls but no change for boys. Together with the gender differences, these data suggest that overall, preschool boys seem to be more affected by symptoms. In this study, we were also interested to identify which symptoms at the baseline assessment predict impairment at the follow-up. As studies by Goodman [27, 37] have shown the ability to discriminate between clinical and community subjects is greater if impairment as well as symptom scores are taken into account. Moreover, impairment serves as a powerful predictor of whether the child will be referred to professionals [28]. The analysis revealed that impairment at baseline, male gender, conduct problems, hyperactivity and peer problems significantly contributed to the explained variance (R2 = 0.243) of the impairment at follow-up. Impairment at baseline had by far the highest beta value. The additionally explained variance of the symptoms was quite small. However, externalizing symptoms seem to play a particularly important role in the longitudinal development of impairment in young children when controlling for
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earlier impairment. This might be explained by the somewhat higher stability of externalizing symptoms we found— hyperactivity had the highest stability of all symptom scales—compared with emotional symptoms. It might also be the case that parents feel more disturbed by externalizing symptoms and thus report more difficulties and impairment in daily life than when their children exhibit emotional symptoms but are very compliant and obedient. Especially peer problems are easily to observe for parents and seem to be relevant for impairment in daily life. This result is in accordance with the earlier findings of Bufferd and colleagues [3]. In their study of the prevalence of psychiatric disorders in 3-year-old children they found that overall psychiatric disorders were associated with psychosocial functioning, with externalizing disorders (ODD and ADHD) having the largest associations. Keenan and colleagues [38] also reported that preschoolers with externalizing disorders were more likely to be rated as impaired than children with internalizing disorders, and this difference was even larger for subthreshold disorders. This study has several significant strengths. It is one of the very few studies to examine the stability and change of emotional and behavioral symptoms in a large community sample of preschoolers, assessed twice during preschool age. Moreover, it investigates the impairment of the children due to their symptoms as well as the symptoms themselves. There are also limitations to the current study. First, data were based solely on parents’ reports and did not include other informants. Moreover, as parents were assessed for both assessment points, there exists the risk of common method variance with inflated stability scores. Second, about 37 % of the baseline sample could not be reached or identified at the follow-up assessment. This might be for several reasons, e.g., parents were not interested in participating in the study again, or they filled in the questionnaire but not the birth date and/or the child’s name necessary for identification, the family moved away, the child’s family name changed, etc. Overall, we could reassess about 63 % of the baseline sample (with contact details); this is a respectable rate, especially if we take into account that the subjects were not contacted by the researchers directly. Subjects participating at both assessment points did not differ significantly from the baseline sample for children’s age and gender, parents’ educational level and employment situation, or for symptoms and impairment. A third limitation is that we only assessed symptoms and impairment and basic socio-demographic variables and no further risk factors for mental health problems in childhood. This was directed at fostering acceptance and participation by the parents. Overall, this study provides interesting insights into the stability and increase/decrease in symptoms and impairment of a large community sample of preschoolers. A
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further longitudinal assessment is desirable in order to acquire data on the course of emotional and behavioral symptoms from preschool to school age. Acknowledgments This study was supported by a grant of the German Research Foundation (DFG) to Kai von Klitzing and Annette M. Klein (KL 2315/1-1). We thank the Public Health Department of the City of Leipzig for cooperating in this study, as well as all families taking part. Conflict of interest of interests.
The authors declare that they have no conflict
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Eur Child Adolesc Psychiatry 13. Ford T, Collishaw S, Meltzer H et al (2007) A prospective study of childhood psychopathology independent predictors of change over three years. Soc Psychiatry Psychiatr Epidemiol 42(12): 953–961. doi:10.1007/s00127-007-0272-2 14. Bufferd SJ, Dougherty LR, Carlson GA et al (2012) Psychiatric disorders in preschoolers: continuity from ages 3 to 6. Am J Psychiatr 169(11):1157–1164. doi:10.1176/appi.ajp.2012.12020268 15. Bongers IL, Koot HM, van der Ende J et al (2003) The normative development of child and adolescent problem behavior. J Abnorm Psychol 112(2):179–192. doi:10.1037/0021-843X.112.2. 179 16. Hoelling H, Kurth B, Rothenberger A et al (2008) Assessing psychopathological problems of children and adolescents from 3 to 17 years in a nationwide representative sample: results of the German health interview and examination survey for children and adolescents (KiGGS). Eur Child Adolesc Psycol 17:34–41. doi:10.1007/s00787-008-1004-1 17. Luby JL, Si X, Belden AC et al (2009) Preschool depression homotypic continuity and course over 24 months. Arch Gen Psychiatry 66(8):897–905 18. van Leeuwen K, Meerschaert T, Bosmans G et al (2006) The strengths and difficulties questionnaire in a community sample of young children in Flanders. Eur J Psychol Assess 22(3):189–197. doi:10.1027/1015-5759.22.3.189 19. Beyer T, Furniss T (2007) Child psychiatric symptoms in primary school. Soc Psychiatry Psychiatr Epidemiol 42(9):753–758. doi:10.1007/s00127-007-0224-x 20. Beyer T, Postert C, Mueller JM et al (2012) Prognosis and continuity of child mental health problems from preschool to primary school results of a four-year longitudinal study. Child Psychiatr Hum Dev 43(4):533–543. doi:10.1007/s10578-012-0282-5 21. Fuchs S, Klein AM, Otto Y et al (2013) Prevalence of emotional and behavioral symptoms and their impact on daily life activities in a community sample of 3 to 5-year-old children. Child Psychiatry Hum Dev 44(4):493–503. doi:10.1007/s10578-012-03439 22. Klein AM, Otto Y, Fuchs S et al (2013) Psychometric properties of the parent-rated SDQ in preschoolers. Eur J Psychol Assess 29(2):96–104. doi:10.1027/1015-5759/a000129 23. Keiley MK, Bates JE, Dodge KA et al (2000) A cross-domain growth analysis. Externalizing and internalizing behaviors during 8 years of childhood. J Abnorm Child Psychol 28(2):161–179. doi:10.1023/a:1005122814723 24. Stanger C, Achenbach TM, Verhulst FC (1997) Accelerated longitudinal comparisons of aggressive versus delinquent syndromes. Dev Psychopathol 9(1):43–58 25. Burns BJ, Costello EJ, Angold A et al (1995) Children’s mental health service use across service sectors. Health Aff 14(3): 147–159. doi:10.1377/hlthaff.14.3.147
26. Fergusson DM, Horwood LJ, Lynskey MT (1993) Prevalence and comorbidity of DSM-III-R diagnoses in a birth cohort of 15 year olds. J Am Acad Child Adolesc Psychiatr 32(6):1127–1134. doi:10.1097/00004583-199311000-00004 27. Goodman R (1999) The extended version of the strengths and difficulties questionnaire as a guide to child psychiatric caseness and consequent burden. J Child Psychol Psychiatry 40(5):791–799 28. Angold A, Messer SC, Stangl D et al (1998) Perceived parental burden and service use for child and adolescent psychiatric disorders. Am J Public Health 88(1):75–80. doi:10.2105/AJPH.88.1. 75 29. Goodman R (1997) The strengths and difficulties questionnaire: a research note. J Child Psychol Psychiatry 38(5):581–586 30. Klasen H, Woerner W, Rothenberger A et al (2003) The German version of the strengths and difficulties questionnaire (SDQDeu)—overview over first validation and normative studies. Prax Kinderpsychol Kinderpsychiatr 52(7):491–502 31. Woerner W, Becker A, Rothenberger A (2004) Normative data and scale properties of the German parent SDQ. Eur Child Adolesc Psychol 13(Suppl 2):II3–II10. doi:10.1007/s00787-0042002-6 32. Goodman R (2001) Psychometric properties of the strengths and difficulties questionnaire. J Am Acad Child Adolesc Psychiatr 40(11):1337–1345. doi:10.1097/00004583-200111000-00015 33. Rothenberger A, Becker A, Erhart M et al (2008) Psychometric properties of the parent strengths and difficulties questionnaire in the general population of German children and adolescents results of the BELLA study. Eur Child Adolesc Psychol 17:99–105. doi:10.1007/s00787-008-1011-2 34. Woerner W, Becker A, Friedrich C et al (2002) Normierung und Evaluation der deutschen Elternversion des strengths and difficulties questionnaire (SDQ). Ergebnisse einer repra¨sentativen Felderhebung. Z Kinder Jugendpsy Psychother 30(2):105–112 35. Stone LL, Otten R, Engels RCME et al (2010) Psychometric properties of the parent and teacher versions of the strengths and difficulties questionnaire for 4-to 12-year-olds. A review. Clin Child Fam Psychol Rev 13(3):254–274. doi:10.1007/s10567-0100071-2 36. Stone LL, Otten R, Ringlever L et al (2013) The parent version of the strengths and difficulties questionnaire. Omega as an alternative to alpha and a test for measurement invariance. Eur J Psychol Assess 29(1):44–50. doi:10.1027/1015-5759/a000119 37. Goodman R, Ford T, Simmons H et al (2000) Using the strengths and difficulties questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. Br J Psychiatry 177:534–539. doi:10.1192/bjp.177.6.534 38. Keenan K, Shaw D, Walsh B et al (1997) DSM-III-R disorders in preschool children from low-income families. J Am Acad Child Adolesc Psychiatr 36(5):620–627
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ORIGINAL CONTRIBUTION
A prospective study of behavioral and emotional symptoms in preschoolers Annette M. Klein • Yvonne Otto • Sandra Fuchs Ina Reibiger • Kai von Klitzing
•
Received: 28 February 2014 / Accepted: 5 June 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract A substantial number of preschool children exhibit psychological symptoms that have an impact on their own and their families’ lives. The aim of the current study was to investigate the prevalence, stability and increase/decrease in emotional and behavioral symptoms and the resultant impairment at two assessment points at preschool age. The sample consisted of 1,034 children drawn from the general population with a mean age of 51 months at t1 and 72 months at t2. Parents completed the Strengths and Difficulties Questionnaire extended version (Goodman, J Child Psychol Psychiatry 38(5):581–586, 1997; Goodman, J Child Psychol Psychiatry 40(5):791– 799, 1999). At t1, 6.9 % of the preschoolers had a total difficulties and 6.8 % a total impact score within the abnormal range. At t2, these scores were 5.7 and 6.2 %, respectively. We found moderate stability of symptoms. From t1 to t2, emotional symptoms and prosocial behavior significantly increased, while hyperactivity, conduct problems, peer problems and total difficulties decreased. The mean total impact score did not change. Boys showed higher levels of symptoms (except emotional symptoms) and impact, and lower prosocial behavior, than girls. Moreover, there was a significant time 9 gender interaction, with girls showing a larger decrease in hyperactivity/ inattention and in total difficulties than boys. The stepwise multiple regression analysis revealed that the total impact A. M. Klein (&) Y. Otto S. Fuchs K. von Klitzing Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University of Leipzig, Liebigstr. 20a, 04103 Leipzig, Germany e-mail: [email protected] I. Reibiger Health Department at the Municipal Authority in Leipzig, Leipzig, Germany
score at baseline, male gender, conduct problems, hyperactivity and peer problems significantly contributed to the explained variance of the total impact score at follow-up. This is one of very few studies to examine the stability and change of psychological symptoms in a large community sample of preschoolers, assessed twice during preschool age. Keywords Child mental health Emotional symptoms Behavioral symptoms Stability Preschool age
Introduction A substantial number of preschool-age children exhibit emotional symptoms, conduct problems or symptoms of hyperactivity, which have an impact on their own and their families’ lives. The prevalence rates reported for these symptoms at preschool age differ markedly, and especially between countries, ranging from 4.6 and 7.1 % in Denmark [1] and Norway [2], respectively, to 27.4 % (or 22.5 % when excluding specific phobia) in preschoolers in the USA [3]. Studies in Germany showed prevalence rates of mental health problems of 5.3 % in 3- to 6-year-olds [4] and 12.4 % in 6-year-olds [5]. Research has shown that childhood psychopathology must be taken seriously, as emotional symptoms, conduct problems or hyperactivity are unlikely to be transient and, especially if they remain stable, can impair the child’s functioning and development [6]. A number of studies have investigated the stability of psychological symptoms in preschool and school-age children. Edwards et al. [7] found a remarkably high stability of anxiety symptoms (r = 0.75) in 3- to 5-year-old children over 12 months. But several studies suggest that externalizing problems show more
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stability and persistence than internalizing problems [6, 8– 11]. Verhulst and Van der Ende [12] assessed parentreported mental health of children aged 4–16 five times at 2-year intervals. Stability coefficients decreased with time, but even over a period of 8 years, there was a considerable stability, with r = 0.50 for externalizing and r = 0.39 for internalizing scores. The 2-year correlation coefficients for attention problems, internalizing and externalizing scores as well as the total problem score were greater than r = 0.60. Ford and colleagues [13] also found marked stability of mental health problems over 3 years with r = 0.71 in children aged 5–18 years. By using a categorical approach, Lavigne and colleagues [9] examined the stability of psychiatric disorders in children aged 2–5 years at the first wave of data collection. 344 families participated again 42 through 48 months later. Intraclass correlations were 0.497 for emotional disorders and 0.718 for disruptive disorders, indicating moderate stability. Bufferd and colleagues [14] examined the continuity of specific psychiatric disorders in a community sample of preschoolers (N = 462) from ages 3 to 6. They found, that the three-month rates of disorders were relatively stable. Children meeting criteria for any diagnosis at age 3 were nearly five times as likely as the others to meet criteria for a diagnosis at age 6. Moreover, they found both homotypic (e.g., Anxiety, ADHD) and heterotypic continuity (e.g., between depression and anxiety). Overall, studies investigating stability of emotional and behavioral symptoms or psychiatric disorders in community samples of exclusively preschool children are rare. In contrast, there is good knowledge of gender differences in emotional and behavioral symptoms in preschool and early school age. Many studies found gender differences in externalizing, but not internalizing symptoms, with boys showing more behavior problems and/or hyperactivity [1, 7, 10, 15–18]. Parents often also report a higher level of overall mental health problems for boys in preschool and school age than for girls [1, 18–20]. Our own baseline study with N = 1,738 children between the ages of 3 and 5 years showed that boys had higher mean scores than girls on the subscales for conduct problems, hyperactivity and peer problems, and lower scores on the scale measuring prosocial behavior. Moreover, boys showed a higher level of overall mental health problems and more impairment due to those problems than girls. Boys and girls did not differ in emotional symptoms [21, 22]. In order to investigate the course of symptoms over time and the influence of gender on the course, longitudinal studies with several assessment points are necessary. There have been only a few longitudinal studies of community samples that also included preschoolers. In the study by Keiley and colleagues [23] in which they assessed 405 children annually starting in kindergarten (age 5 years) up
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to seventh grade, mothers reported decreasing externalizing behavior and stable internalizing problems. Bongers and colleagues [15] used a longitudinal multiple birth-cohort design with 2,076 children aged 4–18 years selected from the general population to identify normative developmental trajectories of mental health problems at five assessment points at 2-year intervals. They identified specific trajectories, mostly differing for girls and boys. They found that for internalizing problems, there were no gender differences in childhood, but there was a gender effect on the slope of the trajectory, with girls showing a steeper increase in internalizing problems than boys. Both boys and girls showed normative developmental trajectories of externalizing problems that decreased with age, with boys showing more problems than girls at all ages and a steeper decrease in symptoms than girls. Attention problems showed a linear and quadratic change over time (increasing until age 11 and declining thereafter) with no gender effect on the slope. However, the initial value differed significantly between boys and girls, with boys showing higher attention problems at all ages. Using a similar approach, Stanger and colleagues [24] also reported declining aggressive and delinquent behavior in children initially assessed at ages 4–10 years, again with higher scores for boys than girls. In their longitudinal study with two assessment points, Beyer and colleagues [20] assessed 814 children prior to school entry (t1) and 4 years afterward and found increasing internalizing symptoms and attention problems while externalizing symptoms decreased over time. A cross-sectional study by van Leeuwen et al. [18] revealed higher parent-reported total difficulties scores, emotional symptoms and hyperactivity in children in the age group 6–7 years compared with 4- to 5-year-olds. The crosssectional study of a German representative sample by Ho¨lling and colleagues [16] showed no differences between the age groups 3–6 and 7–10 years for hyperactivity; only 14- to 17-year-olds had a lower mean score. In contrast, the youngest age group 3–6 years showed significantly higher conduct problems than the other age groups. Epidemiological studies predominantly focus on emotional and behavioral symptoms. However, even children with high levels of symptoms rarely receive professional help, sometimes because the families themselves are not concerned about the symptoms [25, 26]. Factors influencing the help-seeking behavior of families include whether parents or teachers perceive a problem and whether symptoms impose a burden on parents, teachers or others [27]. The latter is a powerful predictor of whether or not the child will be referred to professionals [28]. Therefore, it seems highly relevant to assess not only the children’s symptoms, but also whether parents perceive them as problematic, and if so to
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ask about the resulting distress and social impairment for the child. Moreover, it is of interest to identify which symptoms are highly associated with impairment longitudinally as this might be useful in identifying children at risk for chronic mental health problems. Our own baseline study with N = 1,738 children between the ages of 3 and 5 years showed that cross sectionally impairment was predicted by emotional symptoms, conduct problems, hyperactivity and peer problems, with emotional symptoms contributing the most to the explained variance, followed by hyperactivity and conduct problems [21]. Overall, empirical data on the stability and change of emotional and behavioral symptoms and impairment during the preschool years are scarce. Existing longitudinal studies that include preschoolers [9, 14, 15, 20, 23, 24] mostly have a second assessment at school age. In this study, we therefore aimed to investigate the prevalence and stability of emotional and behavioral symptoms and resultant impairment in preschool children aged 3–5 years at the baseline and 5–6 years at the followup assessment. Based on the literature, we expected to find moderate stability of emotional and behavioral symptoms. Second, we investigated whether symptom scores increased or decreased over time, as well as noting gender differences and possible interactions of gender with change over time. In line with the findings reported above, we expected to see increasing emotional symptoms and hyperactivity and decreasing conduct problems. Moreover, we expected gender differences in externalizing but not internalizing symptoms and interactions of gender with change over time. Third, we wanted to explore which symptoms predict later impairment as this could help to identify which children with mental health problems need early intervention.
Method Study design and sample The present study was designed prospectively to explore stability and change in emotional and behavioral symptoms in children drawn from the general population of preschool children in Leipzig, a city with a population of about 520,0001 residents in the eastern part of Germany. The Health Department of this city conducts pediatric and developmental assessments twice during preschool age: first, an optional assessment at the age of 3–5 years and a second obligatory assessment at the age of 5–6 years. In
the latter assessment, school readiness is tested. Parents of children born mainly between July 1, 2005, and June 30, 2006, were invited at these two assessment points to take part in the study and asked to complete a short questionnaire. Participation in the study was voluntary, and parents gave informed consent prior to their inclusion in the study. The study was approved by the appropriate ethics committee. All families received a feedback letter describing their child’s mental health. t1 (baseline) measurements took place between August 2009 and October 2010. Parents received the letter with the invitation to the study via their kindergartens. Of the total number of 3,690 families invited, 1,744 families (47.3 %) returned the questionnaire. Due to missing birth dates, six (0.4 %) subjects had to be excluded. Thus, the baseline sample consisted of 1,738 children, 840 girls (48.4 %) and 898 boys (51.6 %) between the ages of 37 and 63 months (mean age 51 months, SD = 5.2). Table 1 shows the socio-demographic characteristics of the baseline sample. The educational level of parents was found to be representative for the population of parents in the city2 based on data of the State Office of Statistics of Saxony. Of this sample, 94.2 % (N = 1,637) gave contact information (e.g., name of child) and birth date necessary to identify the child at follow-up. At t2 (follow-up), parents had an appointment at the Health Department where the school readiness test of their child took place. There they received a letter with the invitation to take part in our study. Parents were informed that we were interested in the further development of their child and asked to complete the questionnaire and give information (name and birth date) to allow identification of the child. t2 took place between October 2011 and June 2012. Of the total number of 4,299 families invited, 2,626 (61.1 %) filled in the questionnaire. Thus, the t2 sample consisted of 2,626 children, 1,274 girls (48.5 %) and 1,349 boys [51.4 %; N = 3 (0.1 %) missing information on gender] between the ages of 54 and 89 months (mean age 72 months, SD = 4.4). Of these samples, 1,034 families took part at both assessment points and could be clearly identified (63.16 % of the baseline sample with contact details). This sample consisted of 517 girls and 517 boys (each 50.0 %) with a mean age of 51 months (range 37–62 months, SD = 5.2) at t1 and 72 months (range 63–82 months, SD = 3.8) at t2. The mean time between both assessment points was 21 months (range 11–31 months, SD = 4.2). The questionnaire was mainly completed by mothers (t1 83.4 %, t2 82.9 %) and in smaller proportions by fathers (t1 6.0 %, t2 14.4 %), by both parents together (t1 10.1 %, t2 1.6 %) or by other
1
Number of residents 31.12.2012, Statistisches Landesamt des Freistaates Sachsen, http://statistik.leipzig.de/statcity/table.aspx?cat= 2&rub=1&per=q (7.5.2014).
2
Statistisches Landesamt des Freistaates Sachsen, Kamenz, 2014.
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Eur Child Adolesc Psychiatry Table 1 Socio-demographics of the t1 baseline sample (N = 1,738) and the sample taking part at t1 and t2 (N = 1,034) N = 1,738
N = 1,034
At time of data collection t1
51 months (range 37–63; SD = 5.2)
51 months (range 37–62; SD = 5.2)
At time of data collection t2
–
72 months (range 63–82; SD = 3.8)
Boys
898 (51.6)
517 (50.0)
Girls
840 (48.4)
517 (50.0)
Mean age
Gender (%)
Educational level at t1, mother (%) Low school diploma
210 (12.1)
112 (10.8)
High school diploma
875 (50.3)
551 (53.3)
University degree
641 (36.9)
366 (35.4)
Missing
12 (0.7)
5 (0.5)
Educational level at t1, father (%) Low school diploma
199 (11.4)
123 (11.9)
High school diploma
792 (45.6)
472 (45.6)
University degree
649 (37.3)
388 (37.5)
Missing
98 (5.6)
51 (4.9)
Employed at t1, mother (%) Yes
1,335 (76.8)
813 (78.6)
No
386 (22.2)
216 (20.9)
Missing
17 (1.0)
5 (0.5)
Employed at t1, father (%) Yes
1,487 (85.6)
900 (87.0)
No
143 (8.2)
80 (7.7)
Missing
108 (6.2)
54 (5.2)
caregivers (t1 0.5 %, t2 1.1 %). For the demographic features of the sample, see Table 1. These 1,034 participants identified at both assessment points did not differ significantly from the baseline sample of 1,738 families in children’s age and gender, parents’ educational level and vocational situation, or psychological symptoms (all p [ 0.18). Instruments At both assessment points, parents gave basic demographic information about the child (birth date, gender), their own educational level (highest level reached at school/university) and employment situation and completed the German parentrated form of the Strengths and Difficulties Questionnaire extended version (SDQ P4-16) [27, 29, 30]. The SDQ is an internationally used and well-validated 25-item screening instrument that consists of positive and negative attributes of
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the child, which are rated as being not true (0), somewhat true (1) or certainly true (2). The SDQ consists of five subscales, each comprising five items, thus yielding scores between 0 and 10. Four of the SDQ subscales represent symptom scores: emotional symptoms, conduct problems, hyperactivity, and peer problems, with higher scores indicating more problems. These four subscales are summed up to obtain a total difficulties score ranging from 0 to 40. The fifth subscale assesses prosocial behavior, with higher scores indicating more positive behavior. The total difficulties score and scores of the subscales are classified as normal, borderline or abnormal based on the German normative sample (N = 930 children between 6 and 16 years of age) and its derived cut-off scores published by Woerner and colleagues [31]. A few SDQ questions were modified, substituting ‘‘kindergarten’’ for ‘‘school’’ and ‘‘preschool teacher’’ instead of ‘‘teacher’’ as all children were preschoolers. Using the additional impact supplement [27], the parents indicated whether in general they perceived that their child has difficulties in one or more of these areas: emotions, concentration, behavior or relationships. If parents reported a problem, they were asked to answer additional questions about whether these difficulties upset or distress their child and whether they interfere with their child’s everyday life in different areas: home life, friendships, learning and leisure activities. Following the recommendations of Goodman [27], the original 4-point scale (0 = not at all, 1 = only a little distress/impairment, 2 = quite a lot, 3 = a great deal) was converted to a 3-point scale (0 = not at all/only a little distress/impairment, 1 = quite a lot, 2 = a great deal), aggregating ‘‘not at all’’ and ‘‘only a little’’ distress or impairment as these were considered clinically irrelevant. All ratings combined formed the total impact score as a dimensional score. The SDQ is well received by parents as it is brief and also because it addresses children’s strengths. Several studies have established the validity and reliability of the SDQ parent-rated form [32], including the German version [33, 34]. Moreover, a review of 48 studies [35] confirmed that the SDQ is a psychometrically sound measure for assessing children’s mental health problems. Although Cronbach’s a coefficients are usually found to be acceptable, another indicator of reliability, McDonald’s x has been found to be substantially higher [36]. In our t1 sample of 3- to 5-yearolds (N = 1,738), we found moderate Cronbach’s a coefficients for all subscales and the total difficulties score (a = 0.58–0.79); for details see Klein et al. [22]. Statistical analysis Data handling and all statistical analyses were carried out using IBM SPSS Statistics (Statistical Package for the Social Sciences, release 20).
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We calculated intraclass correlation coefficients (twoway mixed model, type absolute agreement) to assess stability of symptoms. We also conducted a mixed-design MANOVA, with assessment time (t1–t2) as within-subjects factor and child gender as between-subjects factor, and the SDQ scales as dependent variables followed by univariate analyses. Finally, we employed a stepwise multiple regression analysis.
Results Frequencies of symptoms/impairment in abnormal range at baseline (t1) and follow-up (t2) At t1, between 3.2 and 11.4 % of the preschoolers had symptoms classified as abnormal, and 2.1 % had abnormally low prosocial behavior. 6.9 % had a total difficulties and 6.8 % a total impact score in the abnormal range. At t2, between 2.9 and 7.1 % had symptoms classified as abnormal, while 1.7 % showed prosocial behavior in the abnormal range. 5.7 % had a total difficulties and 6.2 % a total impact score in the abnormal range. For all frequencies and percentages, see Table 2. Stability of symptoms and impact In order to assess stability of symptoms, we calculated intraclass correlation coefficients (ICC) for all subscales, the total difficulties score and the total impact score. We found a moderate stability of symptoms, with the lowest ICC for prosocial behavior and the highest for hyperactivity; for all ICCs, see Table 3. The stability of the total difficulties score was higher than the stability of the total impact score. Moreover, we wanted to rule out that the stability estimates are spurious associations due to confounding with maternal education. To assess the influence of maternal education on stability of symptoms, we computed Pearson correlations for symptoms t1–t2 with and without
Table 2 Frequencies (percentage) of symptoms/impairment in abnormal range at baseline (t1) and follow-up (t2) (N = 1,034)
controlling for maternal education of the mother at t1 (partial correlations). The values of the Pearson correlations were highly similar to those of the ICCs and were only minimally reduced (reduction in r = 0.01–0.03) when controlling for education of the mother. Change over time, gender effects and time 9 gender interaction The mixed-design MANOVA on all subscales, the total difficulties score and total impact score with assessment time (t1–t2) as within-subjects factor and child gender as between-subjects factor revealed main effects of assessment time, F(6, 1,005) = 38.44, p \ 0.001, g2p = 0.19, and of gender, F(6, 1,005) = 10.50, p \ 0.001, g2p = 0.06. The interaction of assessment time 9 gender was not significant: F(6, 1,005) = 1.39, p = 0.21, g2p = 0.008. Univariate analyses showed that from t1 to t2, emotional symptoms and prosocial behavior significantly increased, while hyperactivity, conduct problems, peer problems and total difficulties significantly decreased. The mean total impact score did not change (for M, F, p and g2p see Table 4). Effect sizes were mostly small, except for hyperactivity (moderate) and prosocial behavior (moderate to large). Boys had significantly higher total difficulties and impact scores and also showed higher levels of conduct problems, hyperactivity and peer problems than girls. Girls on the other hand showed significantly higher prosocial behavior levels than boys. However, the effect sizes of the gender differences were small. There were no significant gender differences in emotional symptoms (for M, F, p and g2p see Table 5). The univariate analyses revealed significant interactions between assessment time 9 gender for hyperactivity, F(1, 1,010) = 4.23, p \ 0.05, g2p = 0.004, and the total difficulties score, F(1, 1010) = 4.71, p \ 0.05, g2p = 0.005, Table 3 Intraclass correlation coefficients for the SDQ t1–t2 (N = 1,034) SDQ
ICC
95 % CI Lower
Upper
t1, N (%)
t2, N (%) Emotional symptoms
0.47***
0.42
0.52
Emotional symptoms
60 (5.8)
70 (6.8)
Conduct problems
0.52***
0.47
0.57
Conduct problems
55 (5.3)
40 (3.9)
Hyperactivity
0.66***
0.60
0.71
Hyperactivity
118 (11.4)
73 (7.1)
Peer problems
0.45***
0.40
0.50
Peer problems
33 (3.2)
30 (2.9)
Prosocial behavior
0.43***
0.33
0.52
Prosocial behavior
22 (2.1)
18 (1.7)
Total difficulties score
0.63***
0.58
0.67
Total difficulties score
71 (6.9)
59 (5.7)
Total impact score
0.45***
0.40
0.50
Total impact score
70 (6.8)
63 (6.2)
*** p B 0.001
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Eur Child Adolesc Psychiatry Table 4 Scale means (SD) at baseline (t1) and follow-up (t2) (N = 1,034) t1, M (SD)
t2, M (SD)
Univariate tests g2p
F Emotional symptoms
1.58 (1.62)
1.69 (1.70)
4.38*
0.004
Conduct problems
1.75 (1.50)
1.42 (1.47)
52.39***
0.049
Hyperactivity
3.44 (2.34)
2.93 (2.25)
78.28***
0.072
Peer problems
1.09 (1.43)
0.93 (1.34)
12.99***
0.013
Prosocial behavior
7.85 (1.59)
8.46 (1.56)
142.32***
0.124
Total difficulties score
7.86 (4.67)
6.97 (4.83)
49.34***
0.047
Total impact score
0.26 (0.76)
0.24 (0.83)
0.951
0.001
MANOVA univariate tests, two-tailed; df = 1, 1,010 * p \ 0.05, ** p \ 0.01, *** p \ 0.001
Table 5 Scale means (SD) for girls and boys (N = 1,034)
Emotional symptoms t1 Emotional symptoms t2 Conduct problems t1 Conduct problems t2 Hyperactivity t1 Hyperactivity t2 Peer problems t1 Peer problems t2 Prosocial behavior t1 Prosocial behavior t2 Total difficulties score t1 Total difficulties score t2 Total impact score t1 Total impact score t2
Boys (N = 517), M (SD)
Girls (N = 517), M (SD)
1.50 1.71 1.85 1.58 3.65 3.25 1.23 1.08 7.59 8.16 8.24 7.62 0.30 0.33
1.65 1.67 1.64 1.27 3.24 2.61 0.95 0.78 8.11 8.76 7.48 6.32 0.23 0.15
(1.59) (1.74) (1.54) (1.54) (2.29) (2.32) (1.52) (1.44) (1.61) (1.65) (4.66) (5.16) (0.81) (0.93)
(1.64) (1.66) (1.44) (1.39) (2.37) (2.14) (1.31) (1.20) (1.53) (1.41) (4.66) (4.39) (0.70) (0.71)
Univariate tests F
g2p
0.33
0.000
10.40**
0.010
16.24***
0.016
15.28***
0.015
44.87***
0.043
14.61***
0.014
8.62**
0.008
MANOVA univariate tests, two-tailed; df = 1, 1,010 * p \ 0.05, ** p \ 0.01, *** p \ 0.001
with girls showing a greater decrease in hyperactivity and total difficulties than boys. Additional analyses showed that the decrease in hyperactivity and total difficulties was significant for both girls [(hyperactivity: F(1, 507) = 58.07, p \ 0.001, g2p = 0.103; total difficulties score: F(1, 507) = 45.46, p \ 0.001,
g2p
= 0.082)] and boys [(hyperac-
tivity: F(1, 503) = 23.63, p \ 0.001, g2p = 0.045; total difficulties score: F(1, 503) = 11.00, p \ 0.001, g2p = 0.021)]. Furthermore, there was a marginal significant interaction between assessment time 9 gender for the total impact score, F(1, 1,010) = 3.56, p = 0.06, g2p = 0.004. Additional analyses revealed that for boys, there was no significant change, F(1, 503) = 0.35, p = 0.55, g2p = 0.001,
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whereas girls showed a significant decrease in the total impact score, F(1, 507) = 4.98, p = 0.03, g2p = 0.010. The interaction of assessment time 9 gender for emotional symptoms also had a tendency toward significance, F(1, 1,010) = 3.23, p = 0.072, g2p = 0.003, with boys showing a significant increase in symptoms, F(1, 503) = 7.57, p = 0.006, g2p = 0.015, while girls showed no change in emotional symptoms, F(1, 507) = 0.43, p = 0.84, g2p = 0.000. Prediction of total impact score at t2 We used a stepwise multiple regression analysis with two steps in order to evaluate the predictive value of the total impact score at t1 (step 1), as well as gender, symptoms and prosocial behavior at t1 (step 2) in explaining the variance of the total impact score at t2. As explained above, the total impact score includes whether families perceive problems and whether symptoms impose a burden on the child both of which are factors influencing the helpseeking behavior. In step 1, the total impact score at t1 was included and explained 20.5 % of the variance of the total impact score at t2 (R2 = 0.205). In step 2, we entered gender, symptoms and prosocial behavior (forced entry) in order to evaluate their predictive value that goes beyond the total impact score at t1. There was a small but highly significant change of the explained variance (R2 = 0.243, DR2 = 0.038, p \ 0.001). Besides the total impact score at t1 (male) gender, conduct problems, hyperactivity and peer problems but not emotional symptoms or prosocial behavior significantly contributed to the explained variance of the total impact score at t2. The total impact score at t1 had the highest beta value (b = 0.36) followed by hyperactivity and peer problems (both b = 0.11). All standardized and non-standardized beta coefficients are listed in Table 6.
Discussion In this study, 6.9 % of the 3- to 5-year-old preschoolers showed total difficulties scores in the abnormal range as rated by their parents, while 6.8 % of the children were rated as impaired by their difficulties. At the follow-up assessment at the age of 5–6 years these rates were 5.7 and 6.2 %, respectively. This is comparable with the prevalence rates reported previously for German preschoolers [4]. The stability of emotional and behavioral symptoms over 21 months was moderate, with the highest stability found for symptoms of hyperactivity and total difficulties
Eur Child Adolesc Psychiatry Table 6 Stepwise multiple regression analysis for prediction of the total impact score t2 from total impact score t1 (step 1) and gender, symptoms and prosocial behavior t1 (step 2) B
SE B
b
Step 1 Constant Total impact score t1 Step 2 Constant
0.11
0.03
0.49
0.03
-0.38
0.15
0.45***
Total impact score t1
0.40
0.04
0.36***
Gender (0 = girls, 1 = boys)
0.11
0.05
0.07*
Emotional symptoms t1
-0.01
0.02
Conduct problems t1
0.05
0.02
-0.02 0.09*
Hyperactivity t1
0.04
0.01
0.11**
Peer problems t1
0.06
0.02
0.11***
Prosocial behavior t1
0.03
0.02
0.05
R2 = 0.205 for step 1, R2 = 0.243 for step 2, DR2 = 0.038, p \ 0.001 * p \ 0.05, ** p \ 0.01, *** p \ 0.001
(ICCs [0.60). The parent-reported impairment was less stable. Emotional symptoms and conduct problems both showed moderate and almost equal stability, with somewhat higher stability reported for conduct problems. This result is broadly in accordance with other studies reporting higher stability for externalizing than internalizing symptoms [6, 8–11]. Moreover, we could rule out that the stability estimates are spurious associations due to confounding with maternal education. Parents reported increasing emotional symptoms and prosocial behavior and decreasing hyperactivity, conduct problems, peer problems and total difficulties between the two assessment time points. The mean total impact score did not change. Most of these findings are in line with the literature and therefore with our expectations. Previous longitudinal studies investigating preschoolers and school children also found increasing internalizing symptoms [15, 20] and decreasing externalizing symptoms over time [15, 20, 23, 24]. Even if the effect sizes of the changes in emotional symptoms and conduct problems were only small, these would be clinically significant on the long run if the development described continued. Moreover, the increase in prosocial behavior was substantial and could be a potential protective factor for the further development of the children. The decrease in symptoms of hyperactivity was unexpected, since several longitudinal studies have revealed increasing hyperactivity until about the end of primary school [15, 20]. The cross-sectional study by van Leeuwen et al. [18] also reported higher hyperactivity in 6- to 7-yearolds than in 4- to 5-year-old children. In contrast, the crosssectional study by Ho¨lling and colleagues [16] showed no
differences in hyperactivity between the age groups 3–6 and 7–10 years. The decrease found in our study might result from a parental overestimation of hyperactivity at the baseline assessment. The SDQ scale describes hyperactive behavior as ‘‘restless, overactive, cannot stay still for long’’, ‘‘easily distracted, concentration wanders’’ and ‘‘thinks things out before acting’’ (not true), which is quite typical behavior for 3–5 year olds. At t1 the mean score was 3.44, somewhat higher than the score of 3.2 in the German representative sample of 3- to 6-year-olds [16]. However, as the SDQ is widely used, we cannot really explain why parents reported a decrease in hyperactivity. Further longitudinal assessment in order to explore trajectories would be very interesting. As we had expected, parent reports in almost all subscales, the total difficulties score and the total impact score differed for boys and for girls. Boys had significantly higher total difficulties and total impact scores and showed higher levels of conduct problems, hyperactivity and peer problems and lower prosocial behavior than girls, albeit with small effect sizes. Only for emotional symptoms were there no significant gender differences. These findings are in accordance with earlier studies investigating preschoolers or primary school children, which typically report higher externalizing problems and overall mental health problems in boys than in girls, but with no gender differences for internalizing problems [1, 7, 10, 15–18]. Furthermore, we found significant interactions of assessment time by gender, although with small effect sizes. Girls showed a larger decrease in hyperactivity and total difficulties than boys. Also, there were marginal significant interactions for emotional symptoms—no change in girls but a significant increase in symptoms for boys— and the total impact score, with a decrease for girls but no change for boys. Together with the gender differences, these data suggest that overall, preschool boys seem to be more affected by symptoms. In this study, we were also interested to identify which symptoms at the baseline assessment predict impairment at the follow-up. As studies by Goodman [27, 37] have shown the ability to discriminate between clinical and community subjects is greater if impairment as well as symptom scores are taken into account. Moreover, impairment serves as a powerful predictor of whether the child will be referred to professionals [28]. The analysis revealed that impairment at baseline, male gender, conduct problems, hyperactivity and peer problems significantly contributed to the explained variance (R2 = 0.243) of the impairment at follow-up. Impairment at baseline had by far the highest beta value. The additionally explained variance of the symptoms was quite small. However, externalizing symptoms seem to play a particularly important role in the longitudinal development of impairment in young children when controlling for
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earlier impairment. This might be explained by the somewhat higher stability of externalizing symptoms we found— hyperactivity had the highest stability of all symptom scales—compared with emotional symptoms. It might also be the case that parents feel more disturbed by externalizing symptoms and thus report more difficulties and impairment in daily life than when their children exhibit emotional symptoms but are very compliant and obedient. Especially peer problems are easily to observe for parents and seem to be relevant for impairment in daily life. This result is in accordance with the earlier findings of Bufferd and colleagues [3]. In their study of the prevalence of psychiatric disorders in 3-year-old children they found that overall psychiatric disorders were associated with psychosocial functioning, with externalizing disorders (ODD and ADHD) having the largest associations. Keenan and colleagues [38] also reported that preschoolers with externalizing disorders were more likely to be rated as impaired than children with internalizing disorders, and this difference was even larger for subthreshold disorders. This study has several significant strengths. It is one of the very few studies to examine the stability and change of emotional and behavioral symptoms in a large community sample of preschoolers, assessed twice during preschool age. Moreover, it investigates the impairment of the children due to their symptoms as well as the symptoms themselves. There are also limitations to the current study. First, data were based solely on parents’ reports and did not include other informants. Moreover, as parents were assessed for both assessment points, there exists the risk of common method variance with inflated stability scores. Second, about 37 % of the baseline sample could not be reached or identified at the follow-up assessment. This might be for several reasons, e.g., parents were not interested in participating in the study again, or they filled in the questionnaire but not the birth date and/or the child’s name necessary for identification, the family moved away, the child’s family name changed, etc. Overall, we could reassess about 63 % of the baseline sample (with contact details); this is a respectable rate, especially if we take into account that the subjects were not contacted by the researchers directly. Subjects participating at both assessment points did not differ significantly from the baseline sample for children’s age and gender, parents’ educational level and employment situation, or for symptoms and impairment. A third limitation is that we only assessed symptoms and impairment and basic socio-demographic variables and no further risk factors for mental health problems in childhood. This was directed at fostering acceptance and participation by the parents. Overall, this study provides interesting insights into the stability and increase/decrease in symptoms and impairment of a large community sample of preschoolers. A
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further longitudinal assessment is desirable in order to acquire data on the course of emotional and behavioral symptoms from preschool to school age. Acknowledgments This study was supported by a grant of the German Research Foundation (DFG) to Kai von Klitzing and Annette M. Klein (KL 2315/1-1). We thank the Public Health Department of the City of Leipzig for cooperating in this study, as well as all families taking part. Conflict of interest of interests.
The authors declare that they have no conflict
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