Quantifying Severity of Preschool-Aged Children’s Internalizing Behaviors: A Daily Diary Analysis

Abstract

A subset of preschool-aged children meets criteria for impairing and persistent anxiety and depression. However, the overlap between normative emotional development and impairing symptoms complicates assessments of internalizing problems in early childhood. Given the benefits of early identification/prevention and avoiding overpathologizing typical development, empirical information is needed to norm expression of internalizing behaviors. In this 14-day online diary study, 609 primary caregivers of 3- to 5-year-old children reported the frequency of children’s daily separation and social anxiety and depressive behaviors and impairment. Item response theory analyses quantified specific frequencies at which each behavior was psychometrically severe/rare. Patterns varied for each behavior; for example, distress when anticipating separation had to occur at least 10 times and sadness at least 35 times over 14 days to be considered severe. Most social anxiety behaviors had to occur approximately every other day to be considered severe. Parameters did not vary by child age or sex, and behaviors were significantly associated with impairment. These data provide empirical information for refining internalizing behavior assessment in preschool-aged children and can be used as benchmarks by child practitioners to assess the extent to which frequencies fall in the range of developmentally typical behavior versus those that may be more severe.

Modeling the normal:abnormal spectrum of early childhood internalizing behaviors: A clinical‐developmental approach for the Multidimensional Assessment Profiles Internalizing Dimensions

“…Using daily diary reports of objective frequency of behavioral occurrence to differentiate typical and atypical manifestations of internalizing behaviors in early childhood, they are the first to characterize the dimensional spectrum of these behaviors. Consistent with our prior work in the disruptive behavior domain (Wakschlag et al., 2014), they have demonstrated that differentiation of typical:atypical internalizing behaviors can be modeled along a severity continuum (Bufferd et al., 2023), and can be distinguished in terms of frequency of occurrence (which varies based on the nature of behavior) and context (Bufferd et al., 2017, 2019).…”

“…This advances application of the science of "when to worry" framework to young children's anxious and depressive behaviors. As we and others have noted (Bufferd et al, 2023;Wakschlag et al, 2018), thresholds of risk vary based on the nature of the behavior. This is also demonstrated across the multiple cross-age papers in this special issue validating the MAPSL-TL Infant-Toddler and Youth versions (Alam et al, 2023;Hirsch et al, 2023;Kirk et al, 2023;.…”

“…This suggests that, unlike the uniform subjective threshold approach for DSM symptoms, different cut‐points could be useful when demarcating developmental thresholds of severity for internalizing behaviors in this age period, depending on the behavior in question. Most crucial in this regard is the distinction between higher frequency behaviors that most children do which become atypical when done very frequently (e.g., daily or more) versus pathognomonic behaviors that do not reflect normative misbehaviors and are abnormal at lower frequencies (Bufferd et al., 2023; Wakschlag et al., 2018). These patterns were broadly similar across anxious and depressive behaviors, and consistent with prior developmental dimensional work in this domain (Bufferd et al., 2023).…”

“…Most crucial in this regard is the distinction between higher frequency behaviors that most children do which become atypical when done very frequently (e.g., daily or more) versus pathognomonic behaviors that do not reflect normative misbehaviors and are abnormal at lower frequencies (Bufferd et al., 2023; Wakschlag et al., 2018). These patterns were broadly similar across anxious and depressive behaviors, and consistent with prior developmental dimensional work in this domain (Bufferd et al., 2023). They are also consistent with patterns we have previously shown for a broad range of disruptive behavior dimensions (including irritability and low concern for others, although specifics vary by behavior of interest (Wakschlag et al., 2018; see also Alam et al., 2023; Hirsch et al., 2023; Kirk et al., 2023; Wiggins, Ureña Rosario, MacNeill et al., 2023).…”

“…Recent methodologic work by Bufferd, Dougherty and Olino has built a critical bridge between developmental and clinical understanding of these early internalizing patterns within a dimensional developmental specification framework (Bufferd et al, 2017(Bufferd et al, , 2019(Bufferd et al, , 2023. Using daily diary reports of objective frequency of behavioral occurrence to differentiate typical and atypical manifestations of internalizing behaviors in early childhood, they are the first to characterize the dimensional spectrum of these behaviors.…”