March 25, 2024 • 11 mins
Around one and 10 preschool age, children, struggle with significant emotional and behavior problems, but it can be incredibly difficult to tell. How can you tell When a preschool age child might need further evaluation?
In this episode, we talk about how to use a brief tool to determine whether a preschools behavior is normal, or may benefit from further evaluation. This tool is called the brief early childhood screening assessment, or the brief ECSA for short.
Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Elise Fallucco (00:21):
Welcome back to psyched for paeds, the child
mental health podcasts forpediatric clinicians.
And for all of us who take careof kids, we're helping you help
kids.
I'm your host, Dr.
Elise Fallucco childpsychiatrist and mom.
We're going to be talking aboutemotional and behavioral
problems in preschool aged kids.
(00:41):
And how common they are.
How easy it is.
To not recognize what's goingon.
And how it can be incrediblyhelpful to identify these kids
early, before these problemsgrow and get them intervention
so that they don't grow up intochildren and adolescents with
more serious psychiatricproblems.
(01:01):
And I'm most excited that I'mgoing to be sharing with you,
how you can use a standardizedtool to help distinguish between
normal developmentally typicalchildhood behavior and red
flags, concerning behavior thatrequires further evaluation and
assessment.
And of course, we're going to besharing with you this free tool
that you can use in yourpractice.
(01:23):
So let's start from the verybeginning.
What we know is that about 10%of preschool aged kids
experienced significantbehavioral and emotional
problems that interfere withtheir lives in childcare
settings at home with theirsiblings, with friends.
I just want to go and restatethat fact.
One out of 10 preschool agedkids have significant behavioral
(01:46):
and emotional problems thatcould benefit from intervention
and treatment.
And yet I think the commonwisdom is we'd like to think
that a lot of these kids willgrow out of these things that
they'll develop and that they'llmature.
And that these problems will goaway.
But the reality is.
That the majority of these kidshave problems that persist into
early childhood.
(02:07):
And into elementary, middle, andhigh school and beyond.
And yet.
It is so easy to miss theseproblems.
It's so easy to push them underthe rug to not realize that
there is something going on.
And in doing so we miss theopportunity for early
intervention and to offersupport to these kids and to
their parents.
(02:28):
To help them feel better andhelp support the parents and
families.
So before I tell you about thisamazing standardized tool that
can help you distinguish betweennormal behavior and something
that requires further evaluationand assessment.
I know what you're thinking.
Another tool, anotherstandardized screening tool.
We are so busy and we have a lotof things that we need to do.
(02:48):
And I just want to remindeverybody that the purpose of
these tools is not only to helpus identify kids at risk that we
might miss.
Also, it's a way to streamlinethe visit and to help us
potentially save time.
And from all of our studies,what we know is that.
By just relying on our clinicalintuition, by just relying on
the exam of the child in theroom for that brief well visit,
(03:12):
we're going to miss a lot ofcases.
And in addition, we know thatvery few parents spontaneously
bring up their own concerns withtheir child's behavior, to their
pediatrician.
And so if we're not using a wellvalidated standardized tool to
help assess things, We're goingto be under identifying these
kids and missing opportunitiesfor early intervention.
(03:33):
One of the most difficult thingsto disentangle when you're
dealing with a preschool agedchild is to figure out what is
normal.
We know that temper tantrums arenormal, but when does it become
something that's more than justnormal?
And if this is a clinicalquestion that we as child
psychiatrists even struggle attimes to parse out.
Can you imagine how difficult itis for parents, particularly new
(03:57):
parents to be able to figure outif what their child is doing is
typical.
Or if this could be a sign thatthey may need further
evaluation.
In order to help cliniciansfigure out if a child is
struggling with significantbehavioral and emotional
problems that could benefit fromfurther evaluation and
potentially treatment.
Our colleagues developed theearly childhood screening
(04:18):
assessment.
Or the exa E C S a for short.
So this screening tool wasspecifically designed to be used
in a primary care setting.
And the exit consists of 36items that caregivers are asked
to complete about their child'sbehavior.
So parents are asked compared toother children this age, how
often does your child exhibitthe following things seems
(04:40):
nervous or worries?
A lot loses their temper toomuch.
Argues with adults is verydisobedient.
And so the parents are asked torate some of these items on a
scale of zero, which is never.
To two, which is always, oralmost always.
And then the really amazing andfantastic part about the ECSA is
(05:00):
that it also containsinformation about the caregiver
themselves.
And so the caregivers are askedto self-report.
Symptoms of depression based onthe patient health
questionnaire, two item as wellas symptoms of caregivers,
stress.
And I want to tell you aboutthese two items that assess
caregiver stress, because Ithink that they're relevant for
the preschool age group, butalso potentially for the rest of
(05:23):
our child's lives.
So these items are one, I feeltoo stressed to enjoy my child.
And two, I get more frustratedthan I want to with my child's
behavior.
So these two stress items arereally picking up on the
dynamics of the caregiver, childrelationship.
And most importantly, they'rezooming in on how the caregivers
emotional wellbeing is affectingtheir ability to take care of
(05:46):
and relate to this child.
And this is such a criticallyimportant issue, especially
during early childhood.
So the relationship between thecaregiver and the child.
Is critical for children helpingto develop their own
self-regulation and their ownemotional and behavioral health.
So it's so important that thisparticular scale is not just
(06:08):
looking at child behaviorproblems in a vacuum, but also
looking at the caregiver'swellbeing because the two
things.
Are so interrelated.
And so when you heard that theexa contained 36 child items,
you might've been thinkingthat's very long.
So, this is the fun part where Iget to tell you a little bit of
a backstory so what I'm going totell you about is a journey that
(06:31):
we went on here locally todevelop and validate a briefer
version of the exa for use inpediatric primary care.
I had the pleasure andopportunity to work with a bunch
of pediatric practices here inJacksonville, Florida.
And we asked them to do a pilotperiod of administering the
ECSA.
Routinely at well visits forkids in the preschool age group.
(06:53):
Well, the ECSA is validated foruse in kids as young as 18
months old.
And then as old as 60 monthsold.
The practices we work with choseto administer it at the 48 month
well visit or the four year wellvisit.
It did not make sense for themto administer it at the 24
month, 36 month, 48 month and 60month visits because there's so
(07:13):
many other competing prioritiesat those other visits, not the
least of which are vaccinationsand autism screening and other
developmental screening.
And the feedback we got fromthem is that the screening tool
help them detect money, morecases than routine history
alone.
Cases, both have children withbehavioral and emotional
problems as well as caregiverswith significant stress or
depression.
(07:34):
They said it was feasible andpractical for use, but perhaps
unsurprisingly, they wereconcerned about the length of
the instrument.
it takes families about five to10 minutes to complete.
But the reality is, is if you'rea parent in a pediatrician
office with a preschoolercrawling around your lap and
running around the room.
(07:54):
Completing 40 items feels likeit takes a lot longer than five
to 10 minutes.
The reason why I tell you all ofthat is that based on their
feedback, I had the pleasure towork with one of the developers
of the original ECSA Dr.
Mary Margaret Gleason, who is anchild and adolescent
psychiatrist who specializes inearly childhood, emotional and
behavioral problems.
(08:15):
And Dr.
Gleason and I use their feedbackto develop and validate a much
shorter version of the ECSA.
Called the brief ECSA.
Instead of having 36 items ofchild symptoms.
We developed a version andvalidated a version that only
includes 22 items.
And this briefer version of theECSA It has a cutoff score of
(08:37):
nine or higher.
And has 89% sensitivity and 85%specificity for identifying
children with significantbehavioral and emotional
problems who could benefit fromfurther assessment.
We also validated it againstvery well-known screening tools
and instruments such as thechild behavior checklist, the
(08:58):
pediatric symptom checklist,which I know all of our friends
in pediatric primary care knowand love, the brief infant
toddler, social emotionalassessment to name a few.
So, what I would suggest for youto consider is to take a look at
the brief ECSA, this tool with22 child items.
And then of course, the twocaregivers stress and two
caregiver, depression items.
(09:19):
It's very simple to administerand score.
You just add up all of the itemsthat are endorsed as positive in
column one and column two, toget a total score and scores of
nine or higher are concerning.
And as usual, the higher thescore, the more concerned you
would be.
And for those who scorepositive.
We'd recommend following up,talking with the family.
(09:41):
Not only about their child'sbehavioral and emotional
problems, but checking in.
With the parents about their ownlevel of stress and depression.
And this is an importantopportunity to just open the
door and do what so many primarycare pediatric clinicians are
fantastic at and just validatethe family experience, validate
that it's really hard to betaking care of kids.
In this age group.
(10:03):
Really kids in any age group andespecially for first time
parents, and particularly forparents without a large system
of social support.
So my hope is that you'll tryusing this.
You'll be able to identify kidswho need help and that.
You will then become anothersource of support for these
families.
And if needed may be able topoint some of these families in
(10:26):
the direction of furtherevaluation, additional support I
know you have so many screeningtools that you already use and
have to do, but I hope you knowand trust that when we talk
about a screening tool on thesite for paeds podcast, More
often than not, we'rerecommending it because we feel
that it not only offers you.
Highly valuable clinicalinformation.
(10:47):
But that it ultimately helpssave you time in making your own
clinical assessment anddetermining the priority of the
visit.
So I would suggest that youconsider using this at four year
old well visits.
As usual, you can access freecopies of the brief ECSA on our
website, psyched the number fourpaeds.com.
We're going to continue theconversation about emotional and
(11:09):
behavioral problems.
In our little kids.
Next week and we hope you'lljoin us.
Thanks for listening.
See you next time.
Welcome back to psyched for paeds, the child
mental health podcasts forpediatric clinicians.
And for all of us who take careof kids, we're helping you help
kids.
I'm your host, Dr.
Elise Fallucco childpsychiatrist and mom.
We're going to be talking aboutemotional and behavioral
problems in preschool aged kids.
(00:41):
And how common they are.
How easy it is.
To not recognize what's goingon.
And how it can be incrediblyhelpful to identify these kids
early, before these problemsgrow and get them intervention
so that they don't grow up intochildren and adolescents with
more serious psychiatricproblems.
(01:01):
And I'm most excited that I'mgoing to be sharing with you,
how you can use a standardizedtool to help distinguish between
normal developmentally typicalchildhood behavior and red
flags, concerning behavior thatrequires further evaluation and
assessment.
And of course, we're going to besharing with you this free tool
that you can use in yourpractice.
(01:23):
So let's start from the verybeginning.
What we know is that about 10%of preschool aged kids
experienced significantbehavioral and emotional
problems that interfere withtheir lives in childcare
settings at home with theirsiblings, with friends.
I just want to go and restatethat fact.
One out of 10 preschool agedkids have significant behavioral
(01:46):
and emotional problems thatcould benefit from intervention
and treatment.
And yet I think the commonwisdom is we'd like to think
that a lot of these kids willgrow out of these things that
they'll develop and that they'llmature.
And that these problems will goaway.
But the reality is.
That the majority of these kidshave problems that persist into
early childhood.
(02:07):
And into elementary, middle, andhigh school and beyond.
And yet.
It is so easy to miss theseproblems.
It's so easy to push them underthe rug to not realize that
there is something going on.
And in doing so we miss theopportunity for early
intervention and to offersupport to these kids and to
their parents.
(02:28):
To help them feel better andhelp support the parents and
families.
So before I tell you about thisamazing standardized tool that
can help you distinguish betweennormal behavior and something
that requires further evaluationand assessment.
I know what you're thinking.
Another tool, anotherstandardized screening tool.
We are so busy and we have a lotof things that we need to do.
(02:48):
And I just want to remindeverybody that the purpose of
these tools is not only to helpus identify kids at risk that we
might miss.
Also, it's a way to streamlinethe visit and to help us
potentially save time.
And from all of our studies,what we know is that.
By just relying on our clinicalintuition, by just relying on
the exam of the child in theroom for that brief well visit,
(03:12):
we're going to miss a lot ofcases.
And in addition, we know thatvery few parents spontaneously
bring up their own concerns withtheir child's behavior, to their
pediatrician.
And so if we're not using a wellvalidated standardized tool to
help assess things, We're goingto be under identifying these
kids and missing opportunitiesfor early intervention.
(03:33):
One of the most difficult thingsto disentangle when you're
dealing with a preschool agedchild is to figure out what is
normal.
We know that temper tantrums arenormal, but when does it become
something that's more than justnormal?
And if this is a clinicalquestion that we as child
psychiatrists even struggle attimes to parse out.
Can you imagine how difficult itis for parents, particularly new
(03:57):
parents to be able to figure outif what their child is doing is
typical.
Or if this could be a sign thatthey may need further
evaluation.
In order to help cliniciansfigure out if a child is
struggling with significantbehavioral and emotional
problems that could benefit fromfurther evaluation and
potentially treatment.
Our colleagues developed theearly childhood screening
(04:18):
assessment.
Or the exa E C S a for short.
So this screening tool wasspecifically designed to be used
in a primary care setting.
And the exit consists of 36items that caregivers are asked
to complete about their child'sbehavior.
So parents are asked compared toother children this age, how
often does your child exhibitthe following things seems
(04:40):
nervous or worries?
A lot loses their temper toomuch.
Argues with adults is verydisobedient.
And so the parents are asked torate some of these items on a
scale of zero, which is never.
To two, which is always, oralmost always.
And then the really amazing andfantastic part about the ECSA is
(05:00):
that it also containsinformation about the caregiver
themselves.
And so the caregivers are askedto self-report.
Symptoms of depression based onthe patient health
questionnaire, two item as wellas symptoms of caregivers,
stress.
And I want to tell you aboutthese two items that assess
caregiver stress, because Ithink that they're relevant for
the preschool age group, butalso potentially for the rest of
(05:23):
our child's lives.
So these items are one, I feeltoo stressed to enjoy my child.
And two, I get more frustratedthan I want to with my child's
behavior.
So these two stress items arereally picking up on the
dynamics of the caregiver, childrelationship.
And most importantly, they'rezooming in on how the caregivers
emotional wellbeing is affectingtheir ability to take care of
(05:46):
and relate to this child.
And this is such a criticallyimportant issue, especially
during early childhood.
So the relationship between thecaregiver and the child.
Is critical for children helpingto develop their own
self-regulation and their ownemotional and behavioral health.
So it's so important that thisparticular scale is not just
(06:08):
looking at child behaviorproblems in a vacuum, but also
looking at the caregiver'swellbeing because the two
things.
Are so interrelated.
And so when you heard that theexa contained 36 child items,
you might've been thinkingthat's very long.
So, this is the fun part where Iget to tell you a little bit of
a backstory so what I'm going totell you about is a journey that
(06:31):
we went on here locally todevelop and validate a briefer
version of the exa for use inpediatric primary care.
I had the pleasure andopportunity to work with a bunch
of pediatric practices here inJacksonville, Florida.
And we asked them to do a pilotperiod of administering the
ECSA.
Routinely at well visits forkids in the preschool age group.
(06:53):
Well, the ECSA is validated foruse in kids as young as 18
months old.
And then as old as 60 monthsold.
The practices we work with choseto administer it at the 48 month
well visit or the four year wellvisit.
It did not make sense for themto administer it at the 24
month, 36 month, 48 month and 60month visits because there's so
(07:13):
many other competing prioritiesat those other visits, not the
least of which are vaccinationsand autism screening and other
developmental screening.
And the feedback we got fromthem is that the screening tool
help them detect money, morecases than routine history
alone.
Cases, both have children withbehavioral and emotional
problems as well as caregiverswith significant stress or
depression.
(07:34):
They said it was feasible andpractical for use, but perhaps
unsurprisingly, they wereconcerned about the length of
the instrument.
it takes families about five to10 minutes to complete.
But the reality is, is if you'rea parent in a pediatrician
office with a preschoolercrawling around your lap and
running around the room.
(07:54):
Completing 40 items feels likeit takes a lot longer than five
to 10 minutes.
The reason why I tell you all ofthat is that based on their
feedback, I had the pleasure towork with one of the developers
of the original ECSA Dr.
Mary Margaret Gleason, who is anchild and adolescent
psychiatrist who specializes inearly childhood, emotional and
behavioral problems.
(08:15):
And Dr.
Gleason and I use their feedbackto develop and validate a much
shorter version of the ECSA.
Called the brief ECSA.
Instead of having 36 items ofchild symptoms.
We developed a version andvalidated a version that only
includes 22 items.
And this briefer version of theECSA It has a cutoff score of
(08:37):
nine or higher.
And has 89% sensitivity and 85%specificity for identifying
children with significantbehavioral and emotional
problems who could benefit fromfurther assessment.
We also validated it againstvery well-known screening tools
and instruments such as thechild behavior checklist, the
(08:58):
pediatric symptom checklist,which I know all of our friends
in pediatric primary care knowand love, the brief infant
toddler, social emotionalassessment to name a few.
So, what I would suggest for youto consider is to take a look at
the brief ECSA, this tool with22 child items.
And then of course, the twocaregivers stress and two
caregiver, depression items.
(09:19):
It's very simple to administerand score.
You just add up all of the itemsthat are endorsed as positive in
column one and column two, toget a total score and scores of
nine or higher are concerning.
And as usual, the higher thescore, the more concerned you
would be.
And for those who scorepositive.
We'd recommend following up,talking with the family.
(09:41):
Not only about their child'sbehavioral and emotional
problems, but checking in.
With the parents about their ownlevel of stress and depression.
And this is an importantopportunity to just open the
door and do what so many primarycare pediatric clinicians are
fantastic at and just validatethe family experience, validate
that it's really hard to betaking care of kids.
In this age group.
(10:03):
Really kids in any age group andespecially for first time
parents, and particularly forparents without a large system
of social support.
So my hope is that you'll tryusing this.
You'll be able to identify kidswho need help and that.
You will then become anothersource of support for these
families.
And if needed may be able topoint some of these families in
(10:26):
the direction of furtherevaluation, additional support I
know you have so many screeningtools that you already use and
have to do, but I hope you knowand trust that when we talk
about a screening tool on thesite for paeds podcast, More
often than not, we'rerecommending it because we feel
that it not only offers you.
Highly valuable clinicalinformation.
(10:47):
But that it ultimately helpssave you time in making your own
clinical assessment anddetermining the priority of the
visit.
So I would suggest that youconsider using this at four year
old well visits.
As usual, you can access freecopies of the brief ECSA on our
website, psyched the number fourpaeds.com.
We're going to continue theconversation about emotional and
(11:09):
behavioral problems.
In our little kids.
Next week and we hope you'lljoin us.
Thanks for listening.
See you next time.
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