Behavioural and emotional problems in preschool children
Authors: Maureen M Black, Matthew C H Jukes, Michael T Willoughby
Journal: The Lancet Psychiatry (2017)

In what appears to be the first epidemiological survey in Africa addressing preschool children's behaviour, caregivers in rural Kenya1Kariuki SM Abubakar AA Kombe M et al.Burden, risk factors, and comorbidities of behavioural and emotional problems in Kenyan children: a population-based study.Lancet Psychiatry. 2017; 4: 136-145Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar reported high rates of preschool children (420 [13%] of 3273) with behavioural and emotional problems; 338 (10%) of 3273 had externalising problems and 728 (22%) of 3273 had internalising problems. Historically, behavioural and emotional problems in preschool children have often been disregarded or considered to be transient aspects of children's emerging autonomy. However, longitudinal evidence has shown that preschool children with behavioural and developmental problems are at increased risk of mental health problems throughout childhood and adolescence, particularly if they have co-occurring internalising and externalising problems.2Bornstein MH Hahn C-S Suwalsky JT Developmental pathways among adaptive functioning and externalizing and internalizing behavioral problems: cascades from childhood into adolescence.Appl Dev Sci. 2013; 17: 76-87Crossref PubMed Scopus (38) Google Scholar The consistent patterns from preschool through to adulthood are consistent with the life course perspective of early child development,3Black MM Walker SP Fernald LC et al.Early childhood development coming of age: science through the life course.Lancet. 2016; (published online Oct 3.)http://dx.doi.org/10.1016/S0140-6736(16)31389-7Google Scholar supported at least partially by neuroscientific evidence showing that during the preschool period, brain development is sensitive to the detrimental effects of poverty and adverse childhood experiences4Noble KG Houston SM Brito NH et al.Family income, parental education and brain structure in children and adolescents.Nature Neurosci. 2015; 18: 773-778Crossref PubMed Scopus (712) Google Scholar and to the beneficial effects of maternal support.5Luby JL Belden A Harms MP Tillman R Barch DM Preschool is a sensitive period for the influence of maternal support on the trajectory of hippocampal development.Proc Natl Acad Sci U S A. 2016; 113: 5742-5747Crossref PubMed Scopus (93) Google Scholar Advances in future work can build on current findings1Kariuki SM Abubakar AA Kombe M et al.Burden, risk factors, and comorbidities of behavioural and emotional problems in Kenyan children: a population-based study.Lancet Psychiatry. 2017; 4: 136-145Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar and address gaps in knowledge about behavioural and emotional problems in preschool children in Africa, including cultural and methodological considerations of measuring behavioural problems, risk factors, and prevention. Given the small number of studies of preschool children in Africa, identification of valid assessment methods for behavioural problems might be difficult. Adaptions of the Child Behaviour Checklist (CBCL) have shown good psychometric properties in previous work done by Symon Kariuki and colleagues in Kenya. In a study of the CBCL in over 44 societies,6Rescorla L Ivanova MY Achenbach TM et al.International epidemiology of child and adolescent psychopathology II: integration and applications of dimensional findings from 44 societies.J Am Acad Child Adolesc Psychiatry. 2012; 51: 1273-1283Summary Full Text Full Text PDF PubMed Scopus (118) Google Scholar the two African countries included in the sample were among those with the highest total problem scores and Ethiopia's item ratings correlated least well with those of other countries. The assessment of preschool children's behavioural and emotional problems could be improved by identifying behavioural problems from a local cultural perspective. Such efforts with adolescents in East Africa7Ng LC Kanyanganzi F Munyanah M Mushashi C Betancourt TS Developing and validating the youth conduct problems scale-Rwanda: a mixed methods approach.PLoS One. 2014; 9: e100549Crossref PubMed Scopus (18) Google Scholar found that local mental health terms for some domains, such as depression, map onto those used in existing tools, but are expressed differently. In other domains, such as conduct problems,7Ng LC Kanyanganzi F Munyanah M Mushashi C Betancourt TS Developing and validating the youth conduct problems scale-Rwanda: a mixed methods approach.PLoS One. 2014; 9: e100549Crossref PubMed Scopus (18) Google Scholar a new scale might be needed rather than adaption of existing measures. In addition to cultural considerations, none of the questionnaires routinely used to measure children's behavioural and emotional problems are intended for use with adults with low educational levels. Although reading items to parents might overcome illiteracy, minimally educated parents of preschool children have been shown to have lower expectations about developmentally normative behaviour, compared with better educated parents, particularly in rural settings.8Williams PD Williams AR Lopez M Tayko NP Mothers' developmental expectations for young: children in the Philippines.Int J Nurs Stud. 2000; 37: 291-301Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar There is little information about whether the psychometric properties of questionnaires vary by parental education. Direct assessments of children's executive function abilities, which are related to emotional regulation, might provide a useful supplement to parent questionnaires, particularly in preschool children. Although much of the executive functioning research has been done in developed countries, executive function measures for preschool children can be translated and successfully used in African contexts.9Abubakar A Holding P Van Baar A Newton CR Van de Vijver FJ Espy KA The performance of children prenatally exposed to HIV on the A-Not-B task in Kilifi, Kenya: a preliminary study.Int J Environ Res Public Health. 2013; 10: 4132-4142Crossref PubMed Scopus (12) Google Scholar Kariuki and colleagues showed that perinatal events and medical history, especially seizures, increase the risk of behavioural and emotional problems in rural Kenya.1Kariuki SM Abubakar AA Kombe M et al.Burden, risk factors, and comorbidities of behavioural and emotional problems in Kenyan children: a population-based study.Lancet Psychiatry. 2017; 4: 136-145Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar Other risk factors that are particularly relevant to preschool children in Africa include maternal depressive symptoms, psychosocial deprivation, food insecurity, and violence exposure. Work on the prevention of preschool children's behavioural and emotional problems in Africa could build on emerging global evidence of effective strategies, ranging from child protection laws and prevention of maternal mental health problems to community-based parenting programmes and early child enrichment preschool programmes.10Petersen I Evans-Lacko S Semrau M et al.Promotion, prevention and protection: interventions at the population- and community-levels for mental, neurological and substance use disorders in low- and middle-income countries.Int J Ment Health Syst. 2016; 10: 30Crossref PubMed Scopus (55) Google Scholar Recommended parenting practices include responsive caregiving, early learning, and attention to children's health, nutrition, and safety and security.3Black MM Walker SP Fernald LC et al.Early childhood development coming of age: science through the life course.Lancet. 2016; (published online Oct 3.)http://dx.doi.org/10.1016/S0140-6736(16)31389-7Google Scholar Foster care has been shown to mitigate some of the negative effects of severe psychosocial deprivation, particularly in children placed before the age of 2 years.11McLaughlin KA Fox NA Zeanah CH Nelson CA Adverse rearing environments and neural development in children: The development of frontal electroencephalogram asymmetry.Biol Psychiatry. 2011; 70: 1008-1015Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar The potential of global benefits from prevention and treatment is high, given the prevalence of behavioural problems in preschool children in Africa.1Kariuki SM Abubakar AA Kombe M et al.Burden, risk factors, and comorbidities of behavioural and emotional problems in Kenyan children: a population-based study.Lancet Psychiatry. 2017; 4: 136-145Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar Leaders from throughout the world, including Africa, have implemented the Sustainable Development Goals (SDGs) with the objectives of ending poverty and promoting equity by 2030 through economic growth, education, health, social protection, job opportunities, and environmental protection. Ensuring adaptive behaviours in preschool children can promote a workforce of the future with the health, intelligence, creativity, and altruism necessary to advance the agenda of the SDGs. As the leaders of the WHO, UNICEF, and the World Bank Group have written, “reaching children in the early years is a prerequisite for sustainable development”.12Chan M Lake A Hansen K The early years: silent emergency or unique opportunity?.Lancet. 2016; (published online Oct 3.)http://dx.doi.org/10.1016/S0140-6736(16)31701-9Google Scholar With additional strategies to reduce risk factors associated with preschool children's behavioural problems, to promote a nurturing and supportive environment, and to identify and treat children with behaviour problems, we increase the likelihood of achieving the SDGs globally. We declare no competing interests. Burden, risk factors, and comorbidities of behavioural and emotional problems in Kenyan children: a population-based studyBehavioural and emotional problems are common in preschool children in this Kenyan rural area and are associated with preventable risk factors. Behavioural and emotional problems and associated comorbidities should be identified and addressed in young children. Full-Text PDF Open Access