Introduction

Anxiety disorders are characterized by emotional arousal associated with fear, worry, or nervousness that is out of proportion to the situation. Significant fears in preschool-aged children have been documented since the 1920s,1 but only recently have anxiety disorders in early childhood been widely recognized as impairing and deserving of specialized treatment. Young children’s anxiety often manifests as fearfulness, defiance or tearful outbursts in stressful situations (e.g., separating from a caregiver). Diagnosis of depression in early childhood remains controversial, but symptoms seen in older children, including sadness, appetite/weight problems, sleep problems, low energy and low self-esteem can represent a distinct syndrome in young children.2 To meet diagnostic criteria, symptoms must be severe enough to impair normal functioning. Most young children with depressive symptoms do not meet criteria for a DSM-IV diagnosis, but experts agree that children can experience the core symptoms of depression by age 3.2

In psychopathology research, assessment is designed to capture psychological phenomena to deepen understanding of disorder presentation, course, risk factors and treatments. Assessment in a clinical context refers to gathering screening and/or clinical data to inform clinical judgments regarding the diagnostic presentation of a specific child and to tailor individualized interventions to promote optimal social, academic and family functioning. The key to valid, reliable assessment is employing a multi-method, multi-informant approach that includes repeated clinical observations, diagnostic interview, developmental history, and standardized, comprehensive symptom checklists.3

Subject

Few studies have closely studied the prevalence of psychiatric disorders in preschool-aged children. Research from the United States reported prevalence rates as high as 9% for anxiety disorders and 2% for depression among preschool children.4 A recent study in Scandinavia also found 2% of children to be affected by depression, but rates for anxiety disorders were much lower (1.5%).5 While most childhood fears and transient sadness are normative, some children suffer from emotional problems that cause significant distress and impairment, limiting their ability to develop age-appropriate social and pre-academic skills and/or participate in age-appropriate activities and settings. Assessment is necessary to understand the phenomenology of emotional symptoms and identify young children in need, which is paramount to connecting them with ameliorative services. 

Problems

Researchers struggle to distinguish variations in temperament, (stable individual differences relating to reactivity and self-regulation), from symptoms of psychopathology. There is also inconsistency regarding studying anxiety and depressive symptoms as a single “internalizing domain” or as two clinically-distinct presentations.6,7 Similar issues with how to classify  symptoms are reflected in the lack of consensus as to whether emotional problems should be conceptualized and studied in a categorical versus dimensional fashion.8Diagnostic criteria (DSM-IV-TR)9 are often inappropriate for young children and do not capture developmentally-salient types of impairment (e.g., disruption in family routine), which make it difficult to apply psychiatric research methods. Despite significant advances in the assessment, recognition and treatment of early childhood emotional disorders,10-12 rates of mental health service receipt and participation in prevention programs remain low, especially for ethnic minority children and those living in poverty.13-16

Research Context

Several widely-used parent-report “checklist-style” assessments (e.g., Child Behavior Checklist,17 Infant-Toddler Social and Emotional Assessment,18 Behavior Assessment System for Children19) cover a broad range of functioning, including internalizing, externalizing and other problematic behaviours in early childhood. Other methods include the Preschool Age Psychiatric Assessment,20 a structured diagnostic parent interview, and laboratory observation. Young children are often unable to describe their own emotional experiences using traditional methods. Hence, the Berkeley Puppet Interview uses child-friendly puppets to help preschool-aged children identify symptoms.21 One novel assessment, the Picture Anxiety Test, uses pictures to aid young child report of anxiety.22 

Advancing the study of emotional assessment in young children necessitates a conceptual distinction between temperament and internalizing symptomology. For example, behavioural inhibition (prominent shyness in novel and social situations23) has long been considered a normative temperamental profile that increases risk for developing an anxiety disorder later in childhood,24 but for some children may represent an early onset of disorder.10,25 Unfortunately, most assessments do not capture child or family impairment, which is one way to distinguish between these constructs.

Evidence suggests that anxiety and depressive symptoms are correlated but distinct entities,26 although they are seldom studied separately in young children. Whereas emotional symptoms reflect biological processes and mechanisms, there currently exists no biological “test.” Some psychophysiological assessments (galvanic skin response, heart rate, breathing, pupil dilation, stress cortisol) can identify anxiety-related patterns of autonomic arousal, but a clinical diagnosis still requires diagnostic interview to assess symptom onset, duration, severity and associated impairment. Finally, emotional symptoms tend to be relatively stable throughout childhood if untreated.27,28

Key Research Questions

1. How can assessment methods be improved to minimize reliance on parent report, while still remaining minimally labor-intensive?
2. How can assessments differentiate between temperament and clinically-significant emotional symptoms?
3. What criteria should be used to diagnose anxiety and depressive disorders in young children, or would employing a dimensional approach be advantageous?
4. How can awareness and recognition be improved to increase participation in prevention and early intervention efforts?

Recent Research Results

Significant advances have been made in assessment methods and age-appropriate diagnostic criteria for emotional disorders in young children.29-31Differentiation between symptoms of individual anxiety disorders (e.g., separation anxiety, generalized anxiety) has been found as early as two years of age.6  One novel assessment tool for children aged 3-5, the Preschool Anxiety Scale – Revised, captures these various dimensions of anxiety symptoms.32 In addition, attentional bias to threat has been identified as a possible candidate for assessment of risk for anxiety disorders.33

Regarding depression, novel findings underscore the validity of preschool diagnoses, as well as potential targets for assessments. For example functional magnetic resonance imaging (fMRI), children with a history of preschool-onset depression demonstrated distinct patterns of brain activation, which were similar to those of adults with depression.34 Other research documents that DSM-IV criteria for depression do not adequately capture the disorder's course in preschool-aged children.35 Similar to the heightened awareness regarding preschool depression, evidence suggests that young children can also suffer from post-traumatic stress disorder when age-adjusted diagnostic criteria are employed.36

Research Gaps

More research is needed to fully understand the phenomenology and diagnostic presentation of emotional disorders in young children. This is especially true for depression, which is often difficult to differentiate from behavioural disorders since both are characterized by elevated irritability and reactivity. More research is needed to improve integration of data from observational systems, clinical interviews, child-report assessments and measures of child and family impairment. Research that identifies meaningful ways of distinguishing between temperament and clinically -significant emotional symptoms is also needed. Finally, research is needed on best practices for increasing awareness of clinically significant emotional disturbances in young children to better engage parents, pediatricians and educators in early identification, prevention and intervention efforts.

Conclusions

Recent advances in assessment methods have made it clear that young children can suffer from serious emotional disorders. These disorders are distressing and impairing to young children and their families and present similarly to disorders in older children. Advancements have led to improved assessment methods (i.e., diagnostic interviews, observational systems, child-report assessments, psychophysiological tests) that reduce sole reliance on parent reports and increase diagnostic validity and reliability. Methods for improving the developmental appropriateness of diagnostic criteria for emotional disorders have also been proposed. While these advances mark substantial progress, more research is needed. A lack of consensus remains on the boundary between temperamental variation in emotional reactivity and emotional psychopathology and how to differentiate these constructs. Despite availability, screening tools for identifying young children at risk are underutilized, partly due to limited awareness among pediatricians, parents and educators. Even when identified, rates of parent participation in clinical services, including prevention efforts, remain low. 

Implications for Parents, Services and Policy

The lack of awareness regarding the importance of identifying and ameliorating young children’s emotional disturbances is one of the greatest challenges facing advances in assessment and identification of early childhood emotional problems. This problem is manifested by low levels of treatment-seeking behaviour by parents,14 as well as the rarity of referrals from pediatricians and early educators. Compared with externalizing problems, such as aggression, emotional symptoms tend to be more difficult to recognize and assess, and because they are less disruptive, they are less likely to get noticed. However, it is clear that young children can struggle with distressing and impairing emotional problems that warrant sophisticated assessment and treatment approaches. Emotional disorders interfere with important aspects of development by reducing exposure to challenging situations that are essential for social development and learning. With this in mind, researchers continue to refine assessments and screening measures to identify young children in need of services, but dissemination and broad systems for implementation are still developing.

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