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A substantial proportion of young kids from low-income families had elevated levels of emotional and behavioral health problems seen in pediatric primary care, researchers found.

In a retrospective cohort study of 15,218 children ages 2 to 6 years, fully one-third of children had screening tool scores reflecting clinically elevated levels of emotional and behavioral problems over time, Robert Ammerman, PhD, of Cincinnati Children's Hospital Medical Center, and colleagues reported in .

Relative to those whose scores remained low over time, kids in the elevated score groups were more likely to be male, white, have public insurance, have had a social need, and a caregiver with depression.

"The elevated results we saw reflect significant behavioral problems starting at very early ages," Ammerman said in a statement. "The findings suggest that we cannot afford to wait until children enter school or reach their teen years to intervene. Our field needs to focus much more intently on prevention."

Data for the study were collected as part of routine care in three pediatric primary care offices and three school-based health centers in Ohio serving a primarily low-income population, researchers noted. Caregivers completed the Strengths and Difficulties Questionnaire (SDQ, a behavioral and emotional health screening tool on which higher scores reflect more difficulties) at annual well-child visits from July 2016 to January 2022.

The four trajectory groups reflecting severity were:

• Low-stable (LS) patients, who initially had low SDQ scores that remained low and slightly decreased over time (66.1% of kids)
• Moderate-decreasing (MD) patients, who initially had higher SDQ scores that decreased over time (16.6%)
• Low-increasing (LI) patients, who initially had lower SDQ scores but increased over time (13.1%)
• High-increasing (HI) patients, who initially had high SDQ scores that remained high and slightly increased over time (4.3%)

Compared with patients in the LS trajectory group, patients in the HI group were a relative 7% more likely to be younger gestational age, 2.27-fold more likely to identify as white, and 1.87-fold more likely to be male. Additionally, kids in the HI group were three times more likely to have a caregiver who endorsed one social risk, were half as likely to have private insurance, and 66% more likely to have a caregiver who screened positive for depression. The findings were fairly similar for the MD group.

Compared with patients in the LS group, patients in the LI trajectory group were a relative 54% more likely to be white, roughly two times more likely to be male and to have a caregiver who endorsed a social risk, and 39% more likely to have a caregiver who screened positive for depression. Kids in the LI group were half as likely to have private insurance.

When the three elevated-score trajectory groups were examined relative to one another, compared with patients in the LI group, patients in the HI trajectory group were of younger gestational age (relative risk ratio [RRR] 0.95, 95% CI 0.91-0.98), more likely white (RRR 1.47, 95% CI 1.14-1.89), and more likely to have had a caregiver endorse at least one social risk (RRR 1.45, 95% CI 1.15-1.82).

Compared with patients in the LI group, patients in the MD group were of lower gestational age (RRR 0.96, 95% CI 0.94-0.99) and less likely to be male (RRR 0.80, 95% CI 0.68-0.93).

And compared with patients in the MD group, patients in the HI group were more likely to be white (RRR 1.77, 95% CI 1.41-2.24) and have had a caregiver endorse a social risk (RRR 1.52, 95% CI 1.23-1.87).

Overall, just over half of kids included in the study were male. Most were African American or Black children (68.1%), while 2.0% were Asian, 0.1% were American Indian or Alaska Native, 5.7% were multiracial, 0.2% were Native Hawaiian and other Pacific Islander, and 18.5% were white. Some 6.2% identified as Hispanic and 93.2% as non-Hispanic.

Limitations of the study included that missing data occurred due to inconsistent attendance for well-child visits and point-in-time sampling, Ammerman and colleagues noted. Additionally, risk factors for trajectories were limited to those found in electronic health records data.

Also, though the SDQ has been validated with children ages 2 to 6 years, some studies have "found that developmental invariance is limited for specific symptom types in younger ages, necessitating caution in interpreting findings," Ammerman and colleagues wrote.

Furthermore, an in-depth assessment may provide a more comprehensive picture of clinical severity of depression among caregivers than the brief screen used in this study, they noted. And the SDQ relied on caregiver reports, with other sources of information on child behavior unavailable. "Generalization of findings to other populations and settings is limited," they added.

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