Introduction

Mental health problems among children constitute a significant public health concern. These problems affect around 10–20% of all children [1], and present a wide array of symptoms and varying degrees of severity. Emotional and behavioural problems are some of the most common mental health problems in young children [2], affecting approximately one in eight preschool children [3]. Early identification of individuals in need of support for said problems is important for promoting healthy child development.

Emotional problems in young children refer to difficulties in experiencing, expressing, and regulating emotions in a way that is appropriate to their age and developmental stage [4, 5]. These problems can manifest as excessive fear, sadness, anxieties or worries, significantly impacting the child’s daily functioning and interpersonal relationships. Behavioural problems encompass challenges in regulating behaviours according to social norms, including externalising issues like aggression, defiance, and hyperactivity, as well as difficulties with attention and impulse control. These problems are directed outward and can negatively affect others in the child’s environment. Emotional and behavioural problems are highly prevalent in children with autism spectrum disorder, attention-deficit hyperactivity disorder, intellectual disabilities, and developmental language disorder, significantly affecting their daily lives and development [6]. The phenotypic overlap between autism and emotional and behavioural problems suggests that it is important to assess both types of problems for more accurate diagnoses and interventions [7]. Further, children with developmental

disabilities display more behavioural problems than their typically developing peers [8, 9].

Studies indicate that emotional and behavioural problems are stable over time, even when assessed at an early age [10]. Further, higher levels of emotional and behavioural problems in childhood are associated with future psychopathology, including anxiety, depression and somatic health issues, as well as relational problems, substance abuse, poor academic performance, unemployment and criminal behaviour [11–15]. Identifying early signs of emotional and behavioural problems and promptly applying interventions has the potential to mitigate the challenges faced by many families. Introducing standardised and resource-efficient approaches such as questionnaires that possess suitable psychometric qualities, could aid in detecting and preventing escalation of these problems. Moreover, early interventions may positively affect children’s mental well-being in formative years, enhancing engagement in school, families, and society, and lead to lower health-related costs [16].

In Sweden, the child health services (CHS) constitute a vital part of the primary care for children as almost all children visit these services [17]. The CHS aims to promote health, monitor children’s development, and provide parenting support, making them an excellent arena for early identification of emotional and behavioural problems. However, no screening method for detection of such problems is currently used at the national CHS level. The CHS refer children for further interventions and assessment to other health care services such as speech and language pathologists (SLP), paediatricians or psychologists. When there are indications of disabilities, such as intellectual or motor impairments, children are referred to habilitation services for additional assessments and interventions. In many regions of Sweden, a specified neurodevelopmental diagnosis of for instance autism spectrum disorder is required prior to referral to the habilitation services. In the Swedish Region Uppsala, a diagnosis of autism spectrum disorders is set at these services. The habilitation services offer interventions to families of children with intellectual disabilities, autism spectrum disorders, acquired brain injury, and motor disabilities. Children with motor disabilities are commonly identified early and receive timely habilitation interventions.

According to previous research, boys, younger children, and children of parents with lower educational levels are more likely to use habilitation services than girls, older children and children of parents with higher educational levels, respectively [18–20]. In addition, children of ethnic minority parents might underutilize these services due to parental cultural beliefs, stigma or language barriers [21, 22]. At the same time, children of ethnic minority parents have demonstrated elevated risks for both emotional and behavioural problems as well as autism spectrum disorders, thus displaying great need for these services [23, 24]. Moreover, emotional and behavioural problems have been associated with lower parental educational levels [25] and gender, where boys show higher levels of disruptive behaviours and girls more symptoms of worry and anxiety [25, 26]. Also, emotional and behavioural problems have been associated with the child’s age as such problems might display different development pathways across time [26].

As far as we are aware, no Swedish studies have investigated the relation between early emotional and behavioural problems and subsequent use of habilitation services among children. Exploring this association could add knowledge on the usefulness of screening for emotional and behavioural problems, which in turn could facilitate delivery of early interventions and support to those in need. This study aimed to investigate the association between early emotional and behavioural problems and use of habilitation services among children in Sweden. Based on previous international research, we hypothesized that early emotional and behavioural problems would be positively associated with later use of habilitation services in this population [27].

Methods

Participants and procedure

Parents of all children aged 3 to 5 years were recruited from child health centres (CHC) in Uppsala Region during their child’s visit to the health centre for the annual health check-up visit. The nurses from the CHC affixed questionnaires to the appointment reminder letter that were routinely mailed out to every child’s parents 3 weeks prior to the annual check-up. Both parents were instructed to complete one questionnaire each and bring the questionnaires to their child’s visit to the CHC. The questionnaires included the Strengths and Difficulties Questionnaire (SDQ) for assessment of the child’s emotional and behavioural problems [29], items on child demographics, and items on parents’ socio-demographic background. The questionnaires were available in multiple languages including Swedish, English, Arabic, and Somali.

Data were collected over a 4-year period (2013–2017) and at 3, 4, and 5 years of age. For children that were represented more than once, the earliest data point was selected for this study, due to our focus of exploring emotional and behavioural problems in the children when they were at their youngest age. During the study period, a total number of 9496 unique children from Uppsala Region were enrolled in the Focus study, which comprised ratings from mothers and fathers separately. The total participation rate in the Focus study was 48% in study year 1 (2013–2014), 45% in study year 2 (2014–2015), 51% in study year 3 (2015–2016), and 50% in study year 4 (2016–2017) [30]. Among the children enrolled in the Focus-study (n = 9496), we excluded children with missing data on the SDQ and potential confounders (see below) selected for this study. In addition, children whose SDQ ratings were not completed before the child’s first visit to the habilitation centre and whose SDQ ratings did not have a valid assessment date, thus yielding missing data on their follow-up time, were excluded. A total of 7343 and 6322 unique children who were rated by mothers and fathers, respectively, were consequently selected as the study samples of the current study (Fig 1).

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Fig 1. Participant flow-diagram.

https://doi.org/10.1371/journal.pone.0303685.g001

Results

Participant characteristics

The samples were evenly distributed in terms of gender (Table 1). About half of the participants were three years old. Most mothers and fathers were born in Sweden (84.6% and 85.3%) and had higher educational levels (72.7% and 63.6%). About 10% and 13% of the children had identified emotional and behavioural problems as rated by mothers and fathers, respectively. In addition, about 5% and 13% were identified as displaying lack of prosocial behaviour. The mean follow-up time was approximately 80 months. A total of 96 children had been using habilitation services during follow-up. The mean number of visits to a habilitation centre ranged from 1 to 162 visits in total.

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Table 1. Description of child demographics, parental socio-demographics, children’s emotional and behavioural problems and use of habilitation services.

https://doi.org/10.1371/journal.pone.0303685.t001

Associations between emotional and behavioural problems and use of habilitation services

The proportions of boys, according to both mothers’ and fathers’ ratings, were larger among children using habilitation services (84.4%), compared to those not using these services (50.6% and 50.3%) (Table 2). In addition, among children using habilitation services, a larger proportion had identified emotional and behavioural problems (35.4% and 37.5%) and lack of prosocial behaviour (16.7% and 19.8%), according to both mothers’ and fathers’ ratings, than those not using such services (emotional and behavioural problems: 9.7% and 12.4%, lack of prosocial behaviour: 4.9% and 12.8%).

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Table 2. Comparisons of children using and not using habilitation services during follow-up with regard to child demographics, parental socio-demographics, and children’s emotional and behavioural problems.

https://doi.org/10.1371/journal.pone.0303685.t002

In unadjusted Cox regression models (Table 3), children with identified emotional and behavioural problems were more likely to use habilitation services compared to those with no identified problems. These associations were shown for both mothers’ (HR: 5.02) and fathers’ (HR: 4.25) SDQ ratings. In adjusted cox-regression models, the associations remained significant, although relatively lower HR were obtained for both mothers’ (AHR: 4.24) and fathers’ (AHR: 4.03) ratings. Furthermore, children with identified lack of prosocial behaviour were more likely to use habilitation services than those with no identified problems (AHR: 2.67, AHR: 2.14). Finally, boys were more likely to use habilitation services compared to girls (AHR: 5.34, AHR: 5.08).

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Table 3. Unadjusted and adjusted cox regression models for exploring the association between emotional and behavioural problems and use of habilitation services.

Numbers in bold indicate significant (p < 0.05) associations.

https://doi.org/10.1371/journal.pone.0303685.t003

Discussion

This study aimed to investigate the association between early emotional and behavioural problems and use of habilitation services among children in Sweden. The key findings demonstrated that over 30 percent of children using habilitation services had identified emotional and behavioural problems at three to five years of age. In addition, children with these problems, according to both mothers’ and fathers’ SDQ ratings, were more likely to use these services compared to children without such problems. Overall, our results suggest that early emotional and behavioural problems are predictive of use of habilitation services among children in Sweden. This is somewhat expected as older children in the target group of habilitation services, i.e. children with developmental disabilities, display more behavioural problems compared to their typically developing peers [9]. Nonetheless, these problems significantly affect the children’s’ daily lives and development in addition to their developmental disabilities per se [6]. Previous research has proposed that approximately 30–50% of children using similar services as habilitation services also suffer from emotional and behavioural problems, and are thus likely to have mental health treatment needs [27]. Nevertheless, our results show that emotional and behavioural problems were present already at 3–5 years of age and that these early problems predict later use of habilitation services. Further, the SDQ has been shown to predict developmental disabilities such as autism [44, 45] even though this is not the purpose of the instrument. Although some of the SDQ items measure common problems among children with autism, they are not homologous to autism symptoms in general. Thus, using the SDQ as a screening tool specifically for autism could lead to an oversimplification of autism symptomatology, which should be avoided. Rather, the SDQ should be used to measure emotional and behavioral problems, regardless of underlying conditions.

In line with the current findings, a longitudinal study from the Netherlands revealed that parents sought a broader range of support, including child mental health treatment, parental counselling, and specific information for their child’s issues, when their child had both emotional and behavioural problems alongside intellectual disabilities, rather than merely seeking support for intellectual disabilities [46]. As further demonstrated by the results of this study, children with identified lack of prosocial behaviour were more likely to use habilitation services compared to children with no identified problems. In line with our findings, past research has highlighted that parents are inclined to identify early signs of abnormal behaviours in their children when seeking various forms of child mental health interventions, thus, driving their motivation to seek help [47]. Our results, combined with previous research, indicate that families who use habilitation interventions also need support for their child’s emotional and behavioural problems.

Furthermore, in the current study, boys were more likely to use habilitation services compared to girls. This finding is in line with prior research [19]. As demonstrated previously, children who display externalising problems are also more likely to utilise habilitation services, than those without such problems [18]. Given that boys are more likely to exhibit externalising problems compared to girls, boys might be more inclined to consume these services [25, 48]. Our findings, however, revealed that parental socio-demographic factors did not influence use of habilitation services. A plausible rationale supporting this outcome may be that services provided by the CHS in Sweden render information and support to parents regardless of parents’ socio-demographic factors. Nonetheless, the proportions of parents with a high educational level and with Swedish origin were higher in this sample than in the Swedish general population [42]. More parents with lower educational levels and with other origin might have given different results. Additionally, the child’s age was not associated with use of habilitation services. Thus, although the child’s age has been related to habilitation service use in previous research, with younger children more likely to use these services compared to older children [18, 20], the results from this study contradict these findings. Previous studies, however, have included children of a wider age range, i.e., 2–17 years and 6–16 years, than children included in the current study, i.e. 3–5 years. One plausible explanation for our contradictory findings might thus be differences in study populations between the current and previous research.

Overall, our results suggest that early emotional and behavioural problems are important predictors for later use of habilitation services among young children in Sweden. These problems could be identified by using the SDQ within the CHS at the national level. Consequently, this procedure could facilitate delivery of timely interventions to prevent the course of these problems as well as additional negative long-term outcomes. Given the large proportion of children identified with early emotional and behavioural problems among those using habilitation services, habilitation centres could integrate mental health treatment into the standard treatment for children using these services.

Conclusions

Early emotional and behavioural problems predict subsequent habilitation service use among children in Sweden. Establishing a standardised process to assess emotional and behavioural problems at CHS for all children up to 5 years of age could facilitate early identification and delivery of timely interventions. Due to the large proportion of children identified with early emotional and behavioural problems among those using habilitation services, habilitation centres could integrate mental health treatment into the standard treatment for children using these services.

Acknowledgments

We wish to thank all parents and preschool teachers who participated in the study and the nurses at the Child Health Centres who distributed the questionnaires. We are also grateful to all research assistants in the Child Health and Parenting (CHAP) research group for their assistance in the data collection.