Infant & Early Childhood Social-Emotional Screening

Overview

Screening tools for social, behavioral, and emotional problems in infants and toddlers can help primary care providers detect problems early and connect their patients to helpful interventions. Social skills and emotional competencies in infants and toddlers include learning how to:
  • Form secure relationships and build positive relationships
  • Express and regulate emotions
  • Interact appropriately
  • Feel safe exploring the world
  • Communicate effectively
Pediatric social-emotional problems affect up to 10% of young children. [Council: 2016] Problems may include:
  • Autism spectrum disorder
  • Attachment disorders
  • Sleep problems
  • Feeding problems
  • 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. Children’s inherent characteristics, such as fussy temperament, developmental delays, or chronic health issues, can make it harder for others to relate to them and care for them, which in turn can place these children at higher psychosocial risk for abuse or parental depression. The medical home team, childcare providers, and early childhood educators can all help identify risks and protective factors and help families to access support and information.

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

Pearls & Alerts

  • 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. Parents’ own unresolved trauma can negatively influence their ability to be sensitive to the needs of their child.
  • Some of the most effective interventions to build healthy attachments are the cheapest and easiest for caregivers to do, including face-to-face interactions and nurturing touch.
  • Be mindful of diagnostic overshadowing when considering social-emotional screening, especially in the context of exposure to trauma.
  • Mental health assessment and treatment for very young children should be relational in nature 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 child;
    • increasing caregiver skill in responding sensitively to child’s needs;
    • improving parent-child relationship;
    • increasing parental sense of competence.

Screening Recommendations

The American Academy of Pediatrics (AAP) (see [Council: 2016]) recommend:
  • Monitoring for psychosocial and behavioral concerns at every well-child visit. (Currently, there are no AAP guidelines regarding the specific use and timing of psychosocial and mental health screeners in young children.)
  • Screening for autism spectrum disorder at 18 and 24 months, (see Autism Screening) and
  • Screening for developmental delays at 9, 18, and 30 (or 24) months (see Developmental Screening).
  • Performing additional screening for certain children in addition to these ages if parents or a provider have concerns
The use of standardized social-emotional screeners offers better detection than identifying possible delays or problems 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. [Williams: 2018]
Consider selecting critical ages to use standardized screening for social-emotional health of infants and young children in your practice.

Surveillance Tips

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
  • 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.

Social-Emotional Screens

A brief list of commonly-used social-emotional screening tools for primary care is provided. Free resources are listed below. Several additional proprietary and emerging screens are also included as a reference. Contact your state's Medicaid agency for other possible recommended tools.
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, web access)
  • How the screen will be integrated into clinic workflow and medical record
  • How and when to discuss the results with the family
  • Where to refer children for additional testing and support

Early Childhood Screening Assessment (ECSA)

Screens for emotional and behavioral development and maternal distress (see Early Childhood Screening Assessment (PDF Document 44 KB)):
  • Format: 40-item, 5-10 minutes, freely downloadable paper forms, completed by parent and/or childcare provider. Brief ECSA version has 24 items.
  • Age range: 18-60 months
  • Languages: English, Spanish, Romanian
  • Sensitivity= 86%; specificity= 83%
Available for free downloading at Tulane Early Childhood Collaborative (TECC) General Screens.

Spence Children’s Anxiety Scale (SCAS)- Preschool Version

Screens for different types of anxiety (generalized, social, obsessive compulsive, fears of physical injury, trauma, PTSD) (see Preschool Anxiety Scale):
  • Format: 29-34 questions, different forms for parent, teacher
  • Age range: 2.5-6 years
  • Languages: English, Portuguese, Russian
  • Sensitivity/specificity: results are variable for the subscores. Teacher scores have not been validated
Available for free downloading at: The Preschool Anxiety Scale (PAS).

Strengths and Difficulties Questionnaire (SDQ)

Screens for problems with emotions, anxiety/depression, peer relationships, oppositionality/conduct, and prosocial behaviors (see Strengths and Difficulties Questionnaire (SDQ)):
  • Format: 24 questions, parent- and teacher-completed forms (and self-reported forms for 11 and up), and follow up forms
  • Age range: 2-17 years. The early year version is for ages 2-4.
  • Languages: many
  • Reading level: not stated
  • Sensitivity: not stated
Available for free downloading at: The Strengths and Difficulties Questionnaire (SDQ).

Survey of Well-Being of Young Children (SWYC)

Encompasses a variety of screening and surveillance topics at every well-child visit. Some clinical practices use the entire set of tools at every well child check-up, whereas other practices use only 1 component of the set of screens, such as using only the Developmental Milestones. Different scoring algorithms for each component which can be done in Excel or manually, or via the electronic medical record in an integrated eSWYC system.
  • Format: set of age-specific tools usually completed in less than 10 minutes
  • Age range: age specific from 1 month to 5 years 6 months
  • Languages: English, Spanish, Khmer, Burmese, Nepali, Portuguese, Haitian-Creole, and Arabic
  • Sensitivity and specificity of the components are “comparable” to other similar instruments, e.g., ASQ-SE and M-CHAT.
  • Each set includes several screens and questionnaires:
    • Developmental Milestones Checklists: 10-item, age-specific screens for language, fine and gross motor skills, and cognitive development.
    • Baby Pediatric Symptom Checklist (BPSC): An 18-item general behavioral screen for infants 2-17 months.
    • Preschool Pediatric Symptom Checklist: A 25-item screen for behavior and social-emotional issues in toddlers and preschoolers 18-60 months.
    • Parent’s Observations of Social Interactions (POSI): Autism screen for 16- to 30-month-olds; questions are integrated into the 18-, 24-, and 30-month screens
    • Edinburgh Maternal Depression Screen integrated in the 2, 4, and 6 months screens.
    • Family Risk Factors: Questions assembled from other previously validated instruments to screen caregivers for substance abuse, parental depression, inadequate food supply, and domestic violence.
SWYC screens are available for no charge at The Survey of Well-Being of Young Children (Tufts Medical Center).

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

Designed to further investigate social-emotional developmental milestones beyond what is assessed in the ASQ-3. Scoring uses cut-off points for each domain that indicate recommendation for further monitoring or referral.
  • Format: 21 age-specific social-emotional screeners, 10-15 minutes, paper forms, completed by parent/caregiver.
  • Age range: 1 – 72 months
  • Languages: English, Spanish, French
  • Sensitivity= 78-84%; specificity= 76-98%. (see Recommended Screening Instruments.)
Questionnaires are available, for a fee, in English, Spanish, and French from the Brookes Publishing Company at ASQ:SE-2 (Ages and Stages Questionnaire: Social-Emotional).

BASC-3 Behavioral and Emotional Screening System (BASC-3 BESS)

BASC-3 BESS is a tool used to assess behavioral and emotional strengths and weaknesses of children and adolescents in preschool through high school. T-scores provide behavioral and emotional risk stratification into normal, elevated, and extremely elevated. Formal training is not required.
  • Format: 25-30 items, takes 5-10 minutes, versions for teacher, parent, and older students
  • Age range: 3-18 years
Available for purchase at Pearson Assessments.

Brief Infant-Toddler Social-Emotional Assessment (BITSEA)

Designed to screen for social-emotional/behavioral problems and delays in competence. Recent studies have shown promising results for use of the BITSEA to screen for autism spectrum disorders in toddlers, including those who were born prematurely. [Boone: 2018] [Giserman: 2017]
  • Format: 42-item, 7-10 minutes, paper forms, completed by parent/caregiver
  • Age range: 12-36 months
  • Languages: English, Spanish
  • Sensitivity= 85%; specificity= 75%
  • Can be followed up with the Infant-Toddler Social and Emotional Assessment (ITSEA)
Available on a sliding scale at Brief Infant Toddler Social Emotional Assessment (BITSEA).

Caregiver-Teacher Report Form (C-TRF)

Uses ratings from daycare providers & teachers to determine problems, disabilities, what concerns the respondent most about the child, and the best things about the child. Subscales include: Emotionally Reactive; Anxious/Depressed; Somatic Complaints; Withdrawn; Attention Problems; and Aggressive Behavior (see ASEBA).
  • Format: 99 items
  • Age range: 18-60 months

Child Behavior Checklist 1.5-5 (CBCL 1.5-5)

CBCL 1.5-5 is a lengthier screening/assessment tool for Total Problems, Internalizing Problems, and Externalizing Problems). Subscales include: Emotionally Reactive; Anxious/Depressed; Somatic Complaints; Withdrawn; Sleep Problems; Attention Problems; and Aggressive Behavior. Multi-cultural norms are available.
  • Format: over 100 questions. A Spanish form is also available
  • Age range: 18-60 months
Available for purchase at ASEBA.

Devereux Early Childhood Assessment (DECA)

DECA is a lengthier screening and/or assessment tool for assessing protective factors and screening for potential risks in the social and emotional development of children. The system includes specific versions for different age groups including infants (DECA-I), toddlers (DECA-T), and preschoolers (DECA-P2).
  • Format: 33-38 items, completed by parents and/or teachers, paper or online versions.
  • Spanish versions available.
  • Age range: 4 weeks through 5 years
Available for purchase at Center for Resilient Children.

Parents Evaluation of Developmental Status (PEDS)

Captures parent concerns in different developmental domains. May also be useful as a surveillance tool
  • 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 purchase at Parents Evaluation of Developmental Status (PEDS and PEDS:DM).

Temperament and Atypical Behavior Scale (TABS)

Designed for rapid identification of children who should receive more thorough, close-up assessment for developmental issues related to temperament and self-regulation. Available for purchase at Temperament and Atypical Behavior Scale (TABS).

Response to a Positive Screen

Primary Care

When an infant or young child is noted to be at risk for significant problems with social and emotional health, timely referral to evidence-based treatments is key. According to the AAP, these include:

Infant Interventions (Focused on Child-Caregiver Dyad)

  • Infant-parent psychotherapy
  • Video feedback to promote positive parenting
  • Attachment biobehavioral catch-up

Preschool-Aged Interventions

Parent management training models are used for decreasing symptoms of ADHD and disruptive behavior disorders, including:
  • Parent-child interaction therapy (PCIT)*
  • The Incredible Years series*
  • The New Forest Program
  • Triple P (Positive Parenting Program)*
  • Helping the Noncompliant Child
*indicates potential for primary care provision of the intervention
Post-traumatic stress disorder (PTSD) and other trauma-related disorders may be effectively treated with:
  • Trauma-Focused Cognitive-Behavioral Therapy Child-parent psychotherapy
Selective mutism and depression may respond to:
  • Modified PCIT
See modules on Autism Spectrum Disorder, Attention-Deficit/Hyperactivity Disorder (ADHD), Anxiety Disorders, and Depression for more detailed information on diagnosis and treatment of those conditions.

Testing

NEEDS CONTENT

Referrals

There are a variety of services that are available to help treat social-emotional delays or infant mental health problems.

Emerging Screens

At the time of our most recent update, these screens are still under development but may be accessible in the near future or for research purposes.

Welch Emotional Connection Screen (WECS)

  • Description: Assesses the mother-infant emotional connection to identify children at risk for emotional, behavioral and developmental disorders
  • Format: clinician-administered via observation in under 3 minutes. Because it is administered by the clinician, readability information and alternative language versions are not relevant.
  • Age range: newborn to 5 years
  • New tool still undergoing validation. More information at Nurture Science Program (Columbia University Medical Center) (see Welch Emotional Connection Screen (WECS))

Resources

Information & Support

For Professionals

The Adverse Childhood Experiences Study (CDC)
One of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well-being; Centers for Disease Control and Prevention.

Alliance for the Advancement of Infant Mental Health
A global organization linking AIMH state and country infant mental health associations that offer infant and early childhood mental health competencies and endorsements.

Birth to 5: Watch Me Thrive (HHS & DOE) (PDF Document 1007 KB)
An early care and education provider’s guide for developmental and behavioral screening. Contains developmental screening measures for young children and information about the reliability and validity of commonly-used developmental screening tools; U.S. Department of Health and Human Services and U.S. Department of Education, 2014.

Classification of Mental and Developmental Disorders (Zero to Three)
Introduces DC:0–5 (developmentally specific diagnostic criteria and information about mental health disorders in infants and young children), discusses why DC:0–5 is important, and provides policy recommendations.

Developmental Monitoring and Screening for Health Professionals
Information on incorporating developmental screening into the Medical Home and resources for practice as well as patient education.

Early Childhood Mental Health: What is it all about? (PDF Document 33 KB)
This 2001 paper by Cindy Oser, RN, MS at Zero To Three discusses a framework for the context, content, and cornerstones of infant mental health and includes references, links, and resources.

The Infant Mental Health Specialist (PDF Document 686 KB)
This 2000 paper by Deborah J. Weatherston provides information about the skills, clinical strategies, role, and training of an infant mental health specialist.

The National Child Traumatic Stress Network (NCTSN)
In-depth information about trauma-informed clinical interventions, screening and assessment practices, disaster behavioral health response and recovery, culture and trauma, and more.

Zero to Three
A national nonprofit organization that aims to promote the health and development of infants and toddlers, with information and resources for parents and professionals.

For Parents and Patients

Developmental Screening (CDC)
Written for families, this resource provides an overview of screening, the pros and cons of screening tools, links to federal resources; Centers for Disease Control and Prevention.

Parenting (Zero to Three)
A webpage from the Zero to Three national, nonprofit organization dedicated to supporting families and communities in the care of young children. This site has links to FAQs; parenting tips; and reproducible handouts for parents. Topics include behavior, sleep, play, language, and more.

Sound Advice on Mental Health
A collection of interviews with pediatricians about child behavior, emotions and other mental health topics; HealthyChildren.org.

What is Child Traumatic Stress? (NCTSN)
Education and questions and answers about child traumatic stress; National Child Traumatic Stress Network.

Practice Guidelines

American Academy of Pediatrics.
Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening.
Pediatrics (original publication 2006; reaffirmed 2014). 2014;118(1):405-20. PubMed abstract / Full Text
Includes the 5 components of developmental surveillance, screening, follow-up on a positive screen, CPT coding, and an algorithm for assessing development at each pediatric preventive care visit throughout the first 5 years of life.

Council on early childhood; committee on psychosocial aspects of childhood and family health.
Addressing Early Childhood Emotional and Behavioral Problems.
Pediatrics. 2016;138(6). PubMed abstract
Policy statement on how pediatricians can improve the care of young children with emotional, behavioral, and relationship problems; American Academy of Pediatrics.

Patient Education

Emotional and Social Development: 4 to 7 Months
Web page about typical social and emotional milestones for babies. Can be printed as a patient handout in English or Spanish; HealthyChildren.org

Emotional and Social Development: 8 to 12 Months
Web page about typical social and emotional milestones for older babies. Can be printed as a patient handout in English or Spanish; HealthyChildren.org.

Emotional and Social Development: Birth to 3 Months
Web page about typical social and emotional milestones for infants. Can be printed as a patient handout in English or Spanish; HealthyChildren.org.

Fostering Healthy Social and Emotional Development in Young Children Tips for families (PDF Document 209 KB)
6-page printable handout with information for families about promoting positive behaviors in infants and young children and teaching them to develop healthy relationships, build emotional awareness, and improve self-regulation; TalkingIsTeaching.org.

Services for Patients & Families Nationwide (NW)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

Bagner DM, Rodríguez GM, Blake CA, Linares D, Carter AS.
Assessment of behavioral and emotional problems in infancy: a systematic review.
Clin Child Fam Psychol Rev. 2012;15(2):113-28. PubMed abstract / Full Text
A systematic review of assessment procedures used to identify behavioral and emotional problems during infancy.

Newman L, Judd F, Olsson CA, Castle D, Bousman C, Sheehan P, Pantelis C, Craig JM, Komiti A, Everall I.
Early origins of mental disorder - risk factors in the perinatal and infant period.
BMC Psychiatry. 2016;16:270. PubMed abstract / Full Text
Discusses models for understanding the early origins of mental disorder as an important step in elaborating risk reduction strategies.

Pontoppidan M, Niss NK, Pejtersen JH, Julian MM, Væver MS.
Parent report measures of infant and toddler social-emotional development: a systematic review.
Fam Pract. 2017;34(2):127-137. PubMed abstract
A systematic review to identify high quality parent report measures of infant and toddler (0-24 months) social-emotional development for use in primary care settings.

Zwaigenbaum L, Bauman ML, Fein D, Pierce K, Buie T, Davis PA, Newschaffer C, Robins DL, Wetherby A, Choueiri R, Kasari C, Stone WL, Yirmiya N, Estes A, Hansen RL, McPartland JC, Natowicz MR, Carter A, Granpeesheh D, Mailloux Z, Smith Roley S, Wagner S.
Early Screening of Autism Spectrum Disorder: Recommendations for Practice and Research.
Pediatrics. 2015;136 Suppl 1:S41-59. PubMed abstract
This article reviews evidence for autism spectrum disorder (ASD) screening to promote earlier detection and diagnosis, consistent with current American Academy of Pediatrics’ recommendations. The article identifies ASD-specific and broadband screening tools that have been evaluated in large community samples and suggests strategies to help overcome challenges to implementing ASD screening.

Authors & Reviewers

Initial publication: November 2007; last update/revision: January 2020
Current Authors and Reviewers:
Author: Jennifer Goldman-Luthy, MD, MRP, FAAP
Reviewer: Jennifer Mitchell, PhD, BCBA-D
Authoring history
2011: revision: Sarah Winter, MDA; Paul Carbone, MDA
2010: first version: Alfred N. Romeo, RN, PhDCA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

Boone KM, Brown AK, Keim SA.
Screening Accuracy of the Brief Infant Toddler Social-Emotional Assessment to Identify Autism Spectrum Disorder in Toddlers Born at Less Than 30 Weeks' Gestation.
Child Psychiatry Hum Dev. 2018;49(4):493-504. PubMed abstract
This study evaluates the screening accuracy of the Brief Infant Toddler Social-Emotional Assessment (BITSEA) in identifying ASD diagnosis in toddlers born at < 30 weeks' gestation.

Council on early childhood; committee on psychosocial aspects of childhood and family health.
Addressing Early Childhood Emotional and Behavioral Problems.
Pediatrics. 2016;138(6). PubMed abstract
Policy statement on how pediatricians can improve the care of young children with emotional, behavioral, and relationship problems; American Academy of Pediatrics.

Giserman Kiss I, Feldman MS, Sheldrick RC, Carter AS.
Developing Autism Screening Criteria for the Brief Infant Toddler Social Emotional Assessment (BITSEA).
J Autism Dev Disord. 2017;47(5):1269-1277. PubMed abstract / Full Text
Findings highlight feasibility of using the BITSEA, a broadband social-emotional competence and behavior problem screener, to improve early detection of ASD

Graham, MA; White, BA; Clarke, CC; Adams, S.
Infusing infant mental health practices into front-line caregiving.
Infants and Young Children. 2001;14(1):14-23.

Williams ME, Zamora I, Akinsilo O, Chen AH, Poulsen MK.
Broad Developmental Screening Misses Young Children With Social-Emotional Needs.
Clin Pediatr (Phila). 2018;57(7):844-849. PubMed abstract
This study compares improved detection rates of social-emotional and behavioral health problems in young children using the ASQ:SE social emotional screen, compared to a standard developmental screen, ASQ-3. The study also noted that younger children with positive ASQ:SE screens were less likely to obtain referral to mental health care than older children with positive screens.