Pediatric social-emotional problems affect up to 10% of young children. [Council: 2016] Problems may include:

• Autism spectrum disorder
• Attachment disorders
• Attentional difficulties
• Sleep problems
• Feeding problems
• Sensory issues
• Behavioral and emotional problems

Family and environmental risk factors, such as parental depression or substance abuse, poverty, and violence, affect the child’s behavioral and emotional development. Inherent characteristics, such as fussy temperament, developmental delays, or chronic health issues, can make it harder for others to soothe and care for the child, placing them at psychosocial risk for abuse and impacting parental mental health. Likewise, social, emotional, developmental, and mental health will all impact children and their growth. The medical home team, childcare providers, and early childhood educators can all help identify risks and protective factors and help families access support and information.

Social skills and emotional competencies in infants and toddlers include learning how to:

• Form secure, positive relationships
• Express and regulate emotions
• Interact appropriately
• Feel safe exploring the world
• Communicate effectively

Other Names

• Behavioral health screening in infants and toddlers
• Mental health screening in infants and early childhood
• Psychosocial risk assessments for babies and young children

Parent/child interaction
An important factor to consider in screening for a child's social-emotional health is parental sensitivity, including how a parent attends to a child, interprets a child's behaviors, and responds to a child's needs. A parent's unresolved trauma can negatively influence their ability to be sensitive to their child's needs.

Interventions
Some of the most effective interventions to build healthy attachments, including face-to-face interactions and nurturing touch, are the cheapest and easiest for caregivers.

Differential diagnoses
Be mindful of misattributing new clinical symptoms to known psychological difficulties to avoid missing an underlying secondary diagnosis. This is especially important in the context of trauma.

Focus of treatments

Mental health assessment and treatment for very young children should be relational and include caregiver(s). Many of the evidence-based treatments for very young children are focused on one or more of the following key areas:

• Increasing caregiver attunement with the child
• Increasing caregiver skill in responding sensitively to child's needs
• Improving parent-child relationship
• Increasing parental sense of competence

The American Academy of Pediatrics (AAP) recommend:

• Developmental surveillance at each health supervision visit, in addition to assessing family strengths and challenges
• Universal developmental screening at specific ages (see Developmental Screening), including autism screening at 18 and 24 months (see Autism Screening)
• Postpartum Depression Screening at 1 month, 2 months, 4 months, 6 months
• Additional screenings if surveillance reveals any concerns

The Learn the Signs Act Early (CDC) program provides free milestone checklists to support developmental surveillance. In 2022, the milestone checklists were updated by the AAP to reflect milestones most children would be expected to achieve. [Zubler: 2022] This update reflects a more proactive approach to developmental monitoring with the goal of recognizing children with delays so that they can be connected with services as early as possible. Based on average ages, previous checklists were felt to encourage a “wait and see” approach.

The use of standardized social-emotional screeners offers better detection than identifying possible delays from parents’ questions or clinical observations during a busy well- or sick-child visit (surveillance). Both autism and developmental screeners also typically encompass some social-emotional elements that can alert the clinician to a potential problem; however, they are not as sensitive as targeted social-emotional screeners, which may help to identify other behavioral and developmental conditions. [Williams: 2018]

Consider selecting critical ages to use standardized screening for the social-emotional health of infants and young children in your practice.

The following behaviors may indicate social, emotional, behavioral, or mental health problems that merit additional screening or investigation:

Infants and Toddlers

• Displays very little emotion: rarely coos, babbles, or whimpers
• Sad affect - rejects being held or touched
• Unusually difficult to soothe or console
• Extremely fearful or on guard
• Does not turn to familiar adults for comfort or help
• Rare eye contact with caregiver
• Unable to comfort or console self
• Faltering growth
• Feeding and sleep problems
• Cries frequently
• Failure to respond to name (after age 6 months)
• Failure to express interest in others/objects
• Failure to point (12+ months)
• Delay or lack of achieving speech/language milestones

Preschool Children

• Rarely or never engages in pretend play with others or objects
• Very sad or flat affect, withdrawn, expressionless
• Absence or delayed use of language or communication
• Deficits in nonverbal communication (e.g., eye contact, gestures, directed affect)
• Extreme mood swings
• Inappropriate responses to situations (laughs instead of cries when hurt)
• Loss of earlier skills like toileting, language, social or motor skills (regression)
• Reckless behavior, accident-prone, destructive to self or others, frequently fights
• Highly anxious or fearful
• Difficulty paying attention, transitioning between activities, or following instructions
• Faltering growth
• Unusual eating issues like eating non-food objects or vomiting

Adapted from [Graham: 2001]

When these behaviors are observed or reported by the caregiver, consider using a social-emotional screener and/or autism screener to gather more information.

A brief list of commonly used social-emotional screening tools for primary care is provided.

When selecting a screen to use in clinical practice, consider:

• Availability, cost, and psychometric properties of the instrument (e.g., rate of false positives)
• Patient characteristics (e.g., language, reading ability, internet access)
• How the screen will be integrated into the clinic workflow and medical record
• How and when to discuss the results with the family
• Where to refer children for additional testing and support

Ages & Stages Questionnaires, 3rd edition (ASQ-3)

• Sensitivity = 86%, Specificity = 85%
• Age range: 1 month to 5.5 years
• Languages: English, Spanish, Arabic, Chinese, French, Vietnamese

Ages and Stages Questionnaire: Social-Emotional-2nd Ed. (ASQ:SE-2)

Survey of Well-Being of Young Children (SWYC)

Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT–R/F)

Brief Infant-Toddler Social-Emotional Assessment (BITSEA)

Strengths and Difficulties Questionnaire (SDQ)

Early Childhood Screening Assessment (ECSA)

Screens for emotional and behavioral development and maternal distress.

• Format: single parental response form, 10 developmental items per questionnaire, estimated to take 2 minutes to complete, paper and online options.
• Age range: birth to 7 years 11 months • Scoring: algorithm that indicates need for referral, further screening, or continued surveillance
• Languages: over 50
• Sensitivity = 74-80%, Specificity = 70-80%.
• Can be supplemented with concurrent use of Parents’ Evaluation of Developmental Status: Developmental Milestones (PEDS:DM) and other PEDS tools to measure psychosocial risk, resilience, development of NICU graduates, and perform autism-specific screening.

Available for no charge at Early Childhood Screening Assessment (ECSA) ( 25 KB).

Additional Screens

Primary Care

Services & Referrals