Journal of Child Psychology and Psychiatry 45:1 (2004), pp 109–134
Assessment of young children’s social-emotional
development and psychopathology: recent advances
and recommendations for practice
Alice S. Carter,1 Margaret J. Briggs-Gowan2 and Naomi Ornstein Davis1
1
University of Massachusetts Boston, USA; 2Yale University, USA
In the past 10 years tremendous progress has been
made in the conceptualization and measurement of
young children’s social-emotional problems and
competencies and psychopathology. It is now clear
that a significant number of very young children
exhibit psychopathological conditions and that the
problems that emerge in this developmental period
often persist. Simply stated, early emerging psycho-
pathology warrants identification and intervention.
New measures that assess social-emotional prob-
lems and competencies and psychopathology are
available to screen in pediatric practices and child-
care settings, as well as for use in more compre-
hensive evaluations that can be conducted in clinical
and research settings. In this paper, factors that
have contributed to the neglect of young children’s
social-emotional and behavior problems and psy-
chopathology, such as an emphasis on cognitive and
linguistic development and concern regarding stig-
matizing young children and their families, are re-
viewed briefly. Next, some of the inherent challenges
of young child assessment are discussed, including
the rapid developmental changes that characterize
the early childhood period, more limited opportun-
ities that may present for evaluating behavior across
settings, and the importance of understanding
young children’s behavior within relevant develop-
mental, relational and cultural contexts. Finally,
some of the most promising measures developed
over the past decade are reviewed to highlight
advances in a range of assessment methods, includ-
ing parent-report questionnaires, diagnostic inter-
views and observational assessments that are
designed to elicit disorder-specific behavior. In con-
cluding, recommendations for enhancing identifica-
tion and intervention services are offered.
Over the past 10 to 15 years, dramatic progress
has been made in the conceptualization and meas-
urement of very young children’s social-emotional
problems and competencies and psychopathology
(cf., Del Carmen-Wiggins & Carter, 2001, in press;
Zeanah, 2000; Zeanah, Boris, & Larrieu, 1997). This
work builds on research efforts that have begun to
address the manifestation of specific disorders
among very young children (e.g., Keenan & Waks-
chlag, 2000, 2002; Luby, in press; Luby & Morgan,
1997; Schereenga, in press; Schereenga & Zeanah,

Association for Child Psychology and Psychiatry, 2004.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
1994, in press), as well as work that is focused on
examining the prevalence and patterns of problems
and competencies in very young children that are
assessed dimensionally across the continuum of typ-
ical and pathological functioning (e.g., Achenbach &
Rescorla, 2001; Briggs-Gowan, Carter, Skuban, &
Horwitz, 2001; Carter, Briggs-Gowan, Jones, & Lit-
tle, 2003; Mathiesen & Sanson, 2000). Moreover, a
number of new questionnaire and interview assess-
ment tools have been developed that focus specifi-
cally on assessing social-emotional functioning in
infants, toddlers, and preschoolers (cf., Del Carmen
& Carter, in press). Along with advances in con-
ceptual knowledge and measurement approaches, a
deeper understanding and appreciation of some in-
herent challenges facing clinicians and researchers
who conduct social-emotional or mental health
evaluations of very young children has emerged.
Following a bio-ecological, transactional, develop-
mental framework (Bronfenbrenner, 1986; Lerner,
1991; Sameroff, 1995; Sameroff & Chandler, 1975),
we discuss the importance of integrating knowledge
about the individual child’s social-emotional func-
tioning and psychopathological symptoms within the
contexts of the child’s cognitive and developmental
functioning, family relationships, cultural values
and beliefs, and broader family and community risk
factors. Within this framework, we present not only
those promising assessment tools that address very
young children’s social-emotional problems and
competencies and psychopathology, but also review
commonly employed instruments that assess cognit-
ive and developmental functioning, recognizing the
importance of anchoring social-emotional problems
within the context of the child’s developmental level.
In addition, assessment instruments for character-
izing the parent–child or caregiver–child relationship
are described to highlight several approaches for
examining the caregiving context. Finally, we sum-
marize recent approaches to advance understanding
of cultural diversity and competence. A very import-
ant context that is beyond the scope of this paper is
that of the evaluation setting, which may be a pedi-
atric clinic, day care center or Head Start program,
mental health clinic, private practice, or research
setting. For further discussion of these issues see
Huffman and Nichols (in press). In concluding our
110 Alice S. Carter, Margaret J. Briggs-Gowan, and Naomi Ornstein Davis
review of specific instruments, we offer recommen-
dations to encourage applied early detection and
intervention efforts and continued research.
Resistance to acknowledging psychopathology
in young children
Although empirical evidence documents that infants,
toddlers, and young preschoolers suffer from mental
health disturbances that impair their daily activities,
there is still considerable resistance to the notion
that infants and toddlers can exhibit serious and
persistent psychopathology that disrupts develop-
mental adaptation (Emde, 1999, 2001). This neglect
of young children’s mental health has multiple
determinants (McLearn, Knitzer, & Carter, in press).
First, relative to the mental and social-emotional
health of young children, greater emphasis has been
paid to the impact of cognitive and linguistic com-
petence on children’s later adaptive functioning. In
addition, the contributions of children’s early emo-
tional experiences to their capacity to build rela-
tionships (e.g., family, peers, teachers) and as a
foundation for learning (Shonkoff & Phillips, 2000;
Emde, Bingham, & Harmon, 1993) are only recently
being recognized. Additional barriers to focusing
adequate attention on young children’s mental
health include general societal stigma associated
with child mental health (Jellinek, Patel, & Froehle,
2003; US Public Health Service, 2000), parental fear
of blame for the child’s difficulties (McLearn et al., in
press), and cultural differences in belief systems
regarding both children’s development and mental
health service utilization (cf., Jellinek et al., 2003).
A final issue that deserves mention is our societal
nurturance of the myth that childhood, and especi-
ally early childhood, is a ‘sacred,’ happy time. Thus,
parents, day care providers, teachers, pediatricians,
and mental health care providers often avoid dis-
cussion of children’s mental health needs. Indeed,
when a parent shares concern about his or her
child’s social-emotional or behavioral disturbance,
family members and health professionals often
minimize or dismiss the parent’s concerns. Parents
commonly report that when they first shared their
worries, they were told that the problem was likely
transient (i.e., ‘only a stage’) and/or that the parent
was overly anxious. Even when children are suffer-
ing from autism and show marked impairment in
socialization and communication it is not uncom-
mon for there to be a long delay until referral to a
specialist or receipt of a diagnosis (De Giacomo &
Fombonne, 1998; Siegel, Pliner, Eschler, & Elliot,
1988) and for parents to feel that their concerns were
discounted. This is unfortunate, as failure to identify
and address early emerging social-emotional prob-
lems likely leads to the exacerbation of problems
and may diminish parents’ sense of efficacy in the
parenting role. Clinical case review, studies of chil-
dren at high risk for social-emotional and behavior
problems, and empirical studies document that in-
fants and toddlers suffer from emotional problems
including dysregulated mood states, such as pro-
found sadness, disruptive anger, and debilitating
fears (Carter, 2002; Radke-Yarrow, Nottelmann,
Martinez, Fox, & Belmont, 1992; Sameroff & Emde,
1989; Zeanah, 2000; Zeanah et al., 1997; Zero to
Three, 1994).
Prevalence and continuity in early emerging
problem behaviors and psychopathology
Prevalence estimates of parent-reported social-emo-
tional and behavioral problems in 2- and 3-year-old
children have ranged from approximately 7% to 24%,
with the majority falling between 10% and 15%
(Briggs-Gowan et al., 2001; Cornely & Bromet, 1986;
Earls, 1980; Koot & Verhulst, 1991; Larson, Pless, &
Miettinen, 1988; Lavigne et al., 1996; Newth & Cor-
bett, 1993; Richman, Stevenson, & Graham, 1975;
Stallard, 1993; Thompson et al., 1996). With respect
to the infant–toddler period, Jenkins and colleagues
(Jenkins, Bax, & Hart, 1980) documented that ap-
proximately 10% of 1- and 2-year-olds receiving
developmental screening had emotional/behavioral
problems based on parent and pediatrician reports.
In addition, in a preschool-pediatric sample, Lavigne
and his colleagues (1996) reported a prevalence of
approximately 7% for clinician-determined psychi-
atric diagnoses with impairment and 9% for parent–
child problems. Recently, in a healthy birth cohort
living in urban and suburban towns in the Northeast
region of the United States, Briggs-Gowan and col-
leagues (2001) reported a weighted prevalence of
approximately 12% for parent ratings of subclinical
and clinical problems on the Child Behavior Check-
list 2/3 and 6% for clinical level ratings on the Par-
enting Stress Index Difficult Child domain.
Moreover, consistent with the suggestion that early
emerging behavior problems are associated with
child- and family-level impairments, parents who
reported elevated child problem behavior scores were
more likely to report delays in child social-emotional
competence, express worry about their child’s be-
havior, and rate their child’s behaviors as interfering
in family activities (Briggs-Gowan et al., 2001).
There is also evidence that parents can describe their
young children’s social-emotional and behavioral
problems and competencies in a differentiated
manner, distinguishing between problems in
aggression and overactivity as compared with prob-
lems related to anxiety, depression, and social
withdrawal (Carter et al., 2003).
Recent empirical evidence counters the notion that
these early emerging problems are transient in nat-
ure. Indeed, there is a growing body of work that
confirms the persistent nature of infant–toddler so-
cial-emotional and behavioral problems. For exam-
ple, Mathiesen and Sanson (2000) reported that 37%
of 18-month-olds with extreme behavioral/emotional

problems continued to have extreme difficulties at
30 months of age. Similarly, in their pediatric sam-
ple, Lavigne and colleagues (1998) noted that over
half of 2- and 3-year-olds with a psychiatric disorder
continued to have disorder one and two years later.
Other studies have similarly presented moderate
longitudinal stability in parent reports of infant–
toddler emotional/behavioral symptoms (Briggs-
Gowan & Carter, 1998; Keenan, Shaw, Delliquadri,
Giovannelli, & Walsh, 1998; Rose, Rose, & Feldman,
1989). Thus, there is an increasing body of empirical
literature indicating that young children evidence
significant social-emotional and behavior problems
and psychopathology and that these early emerging
problems are likely to persist over time.
Challenges to the assessment of young
children’s social-emotional development
and psychopathology
Defining and assessing social-emotional problems
and psychopathology that emerge in infancy, tod-
dlerhood, and preschool is a challenging process (Del
Carmen-Wiggins & Carter, 2001; Zeanah et al.,
1997). Four factors that complicate the task of
developing age-appropriate assessment strategies
are: (1) the rapid pace of developmental transitions
and growth in early childhood; (2) a lack of guide-
lines for integrating data that are gathered from dif-
ferent sources and methods; (3) limited information
for determining levels of impairment both within the
child and within the family system; and (4) difficulty
assessing child functioning within the relevant rela-
tional and cultural contexts.
Rapid developmental shifts and the
normative context
The rapidly shifting nature of very young children’s
development poses problems for young child
assessment (cf., Zeanah et al., 1997). Specifically,
many behaviors that are considered ‘clinically relev-
ant’ at older ages may be manifestations of normal
development when they appear in early childhood.
For example, a normative increase in oppositional
behaviors and tantrums typically accompanies an
emerging sense of self and pursuit of autonomy in
the second year of life, the period commonly referred
to as the ‘terrible twos.’ Indeed, an absence of temper
tantrums in toddlerhood may be cause for concern,
as tantrums are one way that very young children
assert their newfound sense of autonomy and indi-
viduality. Unless the frequency of these behaviors is
unusually high or the intensity and quality of the
behaviors are markedly distinct from the normative
patterns, these behaviors typically do not reflect the
emergence of psychopathology (Campbell, 1990).
As illustrated by the example of temper tantrums,
some social-emotional and behavioral problems and
psychopathological conditions are characterized by
Infant–toddler assessment 111
the presence of behaviors that emerge during the
typical course of normal development, but that are
exhibited with heightened or reduced frequency,
intensity and/or duration. Alternatively, some so-
cial-emotional and behavior problems and psycho-
pathology are characterized by developmental
deviance, or the presence of unusual behaviors that
are not typical at any age or that are expressed in a
manner that is qualitatively distinct from that seen
among typically developing children. It is relatively
easy to identify deviant behaviors because their
presence at any point in development is cause for
concern. In contrast, when problems are character-
ized by degree of intensity, frequency, or duration of
typically occurring behaviors, it can be much more
difficult to establish the boundary between typical
development and psychopathology.
Discriminating typical from atypical development is
facilitated by focusing on clusters of behaviors or a
related set of relevant symptoms. Given the rapid
shifts in development in the earliest years of life, it is
important both to ensure that behaviors assessed are
developmentally appropriate and to test whether
clusters of behaviors demonstrate age invariance or
are similarly associated across the age span of inter-
est. Generally, the developers of dimensional assess-
ment tools attempt to identify coherent clusters of
problem and/or competence behaviors that are be-
lieved to reflect a shared construct, rather than rely on
single indicators of disturbance. Utilizing both nor-
mative data about the cluster of behaviors and data
about children with known psychopathology, test
developers also establish cut-points within dimen-
sional scales that can be used to assign caseness (e.g.,
clinical or at-risk status). Generally, dimensional
scales inquire about how often a behavior occurs or
how representative a given behavior is of the target
child. In contrast, diagnostic decision making is
informed by the quality of behavioral presentation,
historical information about the onset, offset, fre-
quency, duration, and course of behavior and the
sensitivity of the behavior to contextual cues, as well
as whether or not the behavior is causing distress or
impairment to the child or family. Thus, although
temper tantrums may be normative at specific ages,
the child whose tantrums occur across settings and
caregivers and who evidences extreme or qualitatively
unusual behaviors during tantrums (e.g., tries to hurt
others or destroys toys) may be suffering from a clin-
ical disorder, even if the frequency of tantrums is
appropriate for the child’s age (Egger, 2003a).
Ideally, given the developmental shifts that occur
in early childhood, measures designed to assess
young children’s development will rely on narrow age
bands for comparison. This principle is evident
in the normative tables of the Vineland Adaptive
Behavior Scales (Sparrow, Balla, & Cicchetti, 1984).
In infancy and early toddlerhood, age-bands of
comparison begin at 1-month intervals. After age
2 years, age-bands increase to 2 months. By the
112 Alice S. Carter, Margaret J. Briggs-Gowan, and Naomi Ornstein Davis
time a child is 6 years of age the age band for com-
parison is 3 months. The broadest age band em-
ployed, for older children, is 4 months. The need for
narrow comparison groups is particularly salient for
social-emotional behaviors, such as competencies,
which change at a more dramatic rate through the
infancy, toddler, and preschool period, when com-
pared to problem behaviors (Carter et al., 2003).
Given the dearth of epidemiological or national
standardization data regarding very young children’s
expression of social-emotional/behavioral problems,
determining the boundary between typical develop-
ment and diagnosable psychopathology can present
challenges, particularly when symptom presentation
is not extreme. Indeed, it is quite likely that the ab-
sence of sufficient normative data contributes to the
under-identification of psychopathology in young
children. Fortunately, with the development of new
assessment tools, researchers are now poised to
conduct large-scale epidemiological studies to gather
data on individual behaviors, symptom clusters, and
disorders.
Challenge of integrating data from multiple
sources and informants
A major challenge that persists for clinicians and re-
searchers is determining appropriate methods for
integrating data across different methods and sour-
ces. Existing assessment tools vary with respect to
who provides information about the child, the method
of assessment employed (e.g., questionnaire, inter-
view or observation), and the timeframe that is
covered (e.g., last two weeks, last year, lifetime).
Questionnaires and interviews also vary in terms of
the type of information that is gathered about indi-
vidual symptoms or social-emotional behaviors. For
example, problem behavior checklists (e.g., the CBCL
(Child Behavior Checklist; Achenbach & Rescorla,
2000) and ITSEA (Infant-Toddler Social and Emo-
tional Assessment; Carter et al., 2003)) often have
response formats that cross a rating of the frequency
of the behavior with a rating of whether the behavior is
typical of the child. Although this is sufficient for
identifying children at elevated risk for psychopa-
thology, it does not yield information that is sufficient
for determining clinical diagnostic status. Rather,
structured or semi-structured interviews that include
specific questions about the onset, offset, frequency,
intensity, quality, and context of occurrence are
necessary to determine clinical caseness or to assign
a diagnosis. It is also noteworthy that problem be-
havior checklists often exclude behaviors that are
rare in the population or that have very low base rates
of occurrence because their inclusion compromises
psychometric sufficiency (i.e., reduces internal con-
sistency) (Carter et al., 2003).
Until methods are developed for integrating infor-
mation across assessment sources and methods, the
interpretation of multi-method, multi-informant
data must by informed by knowledge of the strengths
and limitations of different approaches. Dimensional
measures have the following advantages when nor-
mative data are available: (1) allow comparisons of
an individual child’s behavior to a normative refer-
ence group; (2) provide a means to quantify change
in behavior over time and/or pre- and post-inter-
vention; (3) offer an efficient and inexpensive means
to gather information across multiple domains of
social-emotional functioning; and (4) permit profiling
of children’s relative strengths and weaknesses
across domains of social-emotional and behavior
problem areas and competence (Carter, 2002; Eisert,
Sturner, & Mabe, 1991; Glascoe, 2000; Jellinek &
Murphy, 1988). Diagnostic interviews are valuable in
providing systematic and comprehensive assess-
ments of symptom presence, duration, onset, and
diagnostic status, but are less appropriate for scree-
ning (Jellinek & Murphy, 1988). Moreover, assigning
a diagnosis may be necessary to receive appropriate
mental health services (McLearn et al., in press).
Of note, all parent report measures may be subject
to a variety of reporting biases, including possible
distortions associated with parental affective symp-
toms (e.g., Briggs-Gowan, Carter, & Schwab-Stone,
1996; Fergusson, Horwood, & Lynskey, 1995; cf;
Richters, 1992), as well as negative distortion that is
aimed toward receipt of services. Parents also may
under-report for fear of stigma or of involvement by
outside agencies, for example when there is suspi-
cion of child abuse or neglect. Evaluations of young
children also can be complicated by the lack of
multiple informants or contexts in which data about
the child can be gathered. A significant number of
young children live in single parent households or
are cared for in-home by a single primary caregiver.
Due to the potential biases inherent in parent rep-
orts (cf., Briggs-Gowan et al., 1996; Richters, 1992),
relying on a single informant is not ideal. Families
construct meanings of young children’s behavior
based on the history of interactions between the
parents and child, the caregivers’ prior relational
history and cultural values and beliefs (Clark, Tluc-
zek, & Gallagher, in press). The interpretation or
meaning attributed to the child’s behavior influences
the parents’ level of concern about and responses
to the child. Thus, the same set of child behaviors
may evoke widely disparate reactions from different
parents. This poses some problems in distinguishing
children who have social-emotional/behavioral prob-
lems from those whose parents interpret typically
developing behaviors as evidence of a problem.
To avoid over-reliance on parent report, evaluators
can gather information from other caregivers (e.g.,
daycare providers) and include observational
assessments of the child with the parent(s), as well
as in interaction with non-parental figures. Obser-
vations are often believed to be less biased than
parent reports. However, children may be reactive to
a novel setting, compromising the ecological validity

of the observation, and significant low-base rate be-
haviors may be unlikely to emerge in a novel setting.
For this reason, some observational approaches,
such as the ADOS (Autism Diagnostic Observation
Schedule; Lord, Risi, & Lambrecht, 2000) and DB-
DOS (Disruptive Behavior Disorder Observational
Schedule; Wakschlag & Danis, in press), include
presses which are designed to elicit particular types
of problem behaviors or the absence of age-appro-
priate competencies.
When two informants are available to report on a
young child’s behavior or when parent report and
behavior observations are compared, discrepancies
are often found. These discrepancies between the
parent’s report and a second informant’s report or
observational data have been studied in an effort
to describe response biases, which are typically
construed as contributing to measurement error
1 (Briggs-Gowan et al., 1996; cf., Richters, 1992).
Conceiving of differences in reports solely as errors in
measurement may not be accurate, however, be-
cause a parent’s negative appraisal of a child (i.e., the
parent’s internal working model of the child) likely
influences parenting practices and subsequently
child behavior (cf., Fonagy, Target, Steele, & Gerber,
1995; Zeanah, Keener, Anders, & Thomas, 1986).
Therefore, whether or not the caregiver’s report of
elevated social-emotional and behavior problems is
consistent with the child’s actual behavior, the child
whose parent holds a negative appraisal and negative
expectations of him or her is likely at elevated risk for
future problems in social-emotional functioning
(Carter, Garrity-Rokous, Little, & Briggs-Gowan,
2001). Differences in parent and other caregiver
reports also may occur when a family is not from the
dominant culture. In this case, it is critical to eval-
uate the cultural sensitivity of collateral informants
(e.g., child care providers) reporting on children’s
behaviors as well as their knowledge about the family
and cultural frame. Only by examining the cultural
awareness of collateral informants can the evaluator
actively guard against over- or under-pathologizing a
family due to cultural differences that are not
understood by a collateral informant.
Challenge of assessing impairment
Another major challenge in the field of young child
mental health assessment is that of determining and
quantifying impairment. This is particularly critical
when assigning psychopathological diagnoses. For
older children and adults, impairment is child-spe-
cific and hence individual functioning is assessed
(Carter & Del Carmen, in press). The diagnostician
must determine that the individual meets the rel-
evant symptom criteria for a particular disorder and
must document the individual’s inability to perform
and adapt to expectable work, school, relational,
and/or self-care activities and demands. While
clearly central to the diagnostic process, it should be
Infant–toddler assessment 113
recognized that level of impairment also may have
very important implications for studies of dimen-
sional aspects of social-emotional and behavioral
problems and competencies. For example, impair-
ment may be a better predictor of long-term pro-
gnosis than symptom severity or type.
For infants and young children, determining
impairment solely within the individual child may
not be appropriate. Given that young children’s
development is embedded within their caregiving
relationships, it may be more appropriate to consider
both child and family impairments that are secon-
dary to the child’s symptoms. It is possible to develop
a list of specific activities and settings in which lim-
itations due to the child’s psychopathology should be
documented. Aspects of child functioning that
should be addressed include the following: (1)
adaptation to developmentally appropriate demands
and/or specific contexts (e.g., a child is expelled from
several day care centers because his or her behavior
is too challenging and is seen as atypical within the
daycare context); (2) the acquisition of new develop-
mental capacities and skills (e.g., a child’s tactile
sensitivities or fears interfere with his or her explo-
ration of toys and fine motor skills begin to lag); (3)
relationship and interpersonal functioning (e.g., a
child’s impulsivity and attentional problems lead to
difficulties with peers); or (4) health (e.g., a child’s
inability to regulate arousal during feeding leads to
significant weight loss or failure to thrive).
Quite often, however, there may not be clear
markers of impaired functioning despite the pres-
ence of either risk or disorder. This is more likely to
occur with young children because caregivers play a
more active role in regulating the child’s behavior
and emotions (Sameroff & Emde, 1989). To minimize
the impact of psychopathology on children’s day-to-
day functioning, caregivers can provide scaffolding
to maximize the child’s developmental skills and
capacity to adapt within a given environment. For
example, parents may actively avoid settings that
trigger problematic behavior, structure environ-
ments to restrict exposure to overwhelming events,
set limits that minimize the escalation of the child’s
negative behaviors, and provide regulatory strategies
or supports that minimize the child’s expression of
distress. This kind of scaffolding may support com-
petence by aiding the child to develop self-regulatory
strategies but also may compromise competence by
denying children age-appropriate experiences and
opportunities to acquire new skills (Briggs-Gowan
et al., 2001).
Given the embedded nature of the young child’s
emotions and behaviors within the child’s caregiving
relationships, an alternative conceptualization of
the degree of impairment is to explore whether the
child’s psychopathology is impacting not only the
child, but also the family system. Evidence of family
impact would include parental distress or indicators
that the child’s behavior interferes with the parent’s
114 Alice S. Carter, Margaret J. Briggs-Gowan, and Naomi Ornstein Davis
ability to maintain family routines (e.g., eating
together as a family in a restaurant), household
activities (e.g., making a phone call to family mem-
bers or friends), or employment (e.g., stopping or
changing work settings because of difficulty obtain-
ing appropriate child care) (Carter & Del Carmen, in
press). From a developmental-contextual perspec-
tive, it is therefore important to evaluate the func-
tioning of both the child and the family in
determining level of impairment.
Given the difficulties in determining impairment in
young children, few instruments exist to assess the
impact of psychopathology on children’s functioning.
However, one measure that has been used to quan-
tify impairment in very young children is the Vine-
land Adaptive Behavior Scales (Sparrow et al.,
1984). For example, Luby, Heffelfinger, and
Mrakotsky (2003) employed the Vineland for this
purpose in their effort to validate clinical depressive
disorders in preschool-aged children. Although de-
signed to assess adaptive behavior skills, which re-
flect the child’s personal and social sufficiency, this
measure provides a quantitative assessment of the
child’s day-to-day functioning across the following
4 domains: Communication, Daily Living Skills,
Socialization and Motor Skills. The Vineland has
excellent psychometric properties (Sparrow et al.,
1984). The Vineland Expanded Form is recommen-
ded for use with very young children given that it has
more sufficient item density in this age range.
The Social-Emotional Early Childhood Scales
(SEEC; Sparrow, Balla, & Cicchetti, 2001) present
additional normative data for the Vineland Adaptive
Behavior Scales Socialization scale, Expanded Form,
for use with children under 7 years of age. Consis-
tent with the expanded form, this instrument pro-
vides standard scores for the socialization domain.
In addition, standard scores can be computed for
each of the subdomains of Interpersonal Relation-
ships, Playtime and Leisure Time, and Coping Skills.
Although the Vineland does an excellent job of cap-
turing the child’s current functioning, one limitation
is that it does not determine whether lower than
age-expected performance is due to the child’s psy-
chopathological condition(s). Lower scores on the
Vineland may have been evident prior to the onset of
psychopathology, may be associated with develop-
mental delay, and/or may arise because parents do
not expect age-adequate self skills and social suffi-
ciency (e.g., the child achieves a low Daily Living
Skills score because he or she is not expected to or
asked to participate in household chores).
The centrality of understanding early emerging
psychopathology in context
Winnicott’s statement that ‘A baby alone does not
exist’ was intended to convey that children cannot be
considered apart from the caregiver and the context
in which they live (Winnicott, 1965). There is a strong
consensus among researchers and clinicians who
assess early emerging social-emotional and behavi-
oral problems that children must be evaluated
within their caregiving contexts (Clark et al., in
press). However, in addition to considering specific
caregivers, it is also crucial to consider child-level
influences, broader family factors, cultural contri-
butions, and community factors. Both Urie Bron-
fenbrenner’s (1986) bio-ecological model and
Sameroff and Chandler’s (1975) transactional
framework provide useful heuristic models for
understanding these influences on children’s devel-
opment and their implications for the assessment
process. The developmental contextual framework
posited by each of these models argues for a multi-
level assessment strategy.
The caregiving context
Defining the caregiving context. There is general
consensus that understanding the caregiving con-
text is crucial when examining young children’s
developmental trajectories (Sameroff & Emde, 1989).
As young children are highly dependent on external
regulatory supports and therefore are strongly in-
fluenced by caregiving contexts, it is not unusual for
problem behaviors to be specific to context and/or
caregiver. In addition, problem behaviors may reflect
a mismatch between a child’s developmental level
and the situational demands and supports in the
environment. Alternatively, a child who has signific-
ant problem behaviors in many settings may appear
well-regulated with a particular caregiver due to the
unique accommodations and affordances that a
particular caregiver can provide. Problem behaviors
that occur across relational contexts are generally
viewed as of greater concern and suggest that the
child has internalized or learned a style of respond-
ing that has generalized beyond a particular care-
giver or caregiving context.
A first step in understanding the caregiving con-
text is to identify the child’s primary caregivers, the
patterns of current caregiving relationships (e.g.,
how often the child transitions between caregivers),
and the history of the caregiving relationships (e.g.,
multiple transitions, abrupt losses). Parents are of-
ten unaware of the potential impact of caregiving
transitions on very young children. For example, a
child may demonstrate an increase in aggressive
behaviors or social withdrawal subsequent to a
staffing change in his or her day care setting. How-
ever, parents may not make a connection between
the child’s behavior and the loss of contact with a
favorite teacher until they are asked about this se-
quence of events during an interview about caregiv-
ing contexts.
A second feature of the caregiving context that
should be explored is the parents’ definition of family
and who they include in their family constellation.
The diversity of our current society includes a

multitude of family constellations (cf., Carter &
Murdock, 2001). Moreover, family constellations are
dynamic units of social organization that change
across history, setting, culture, circumstance, and
stage of the life cycle. Thus, the task of identifying
the members who should be counted within a given
family can be extremely complicated, with family
members employing different rules for inclusion and
exclusion. Family membership may be defined on
the basis of biological relationships or perceptions of
psychological relationship and may include the nu-
clear family, larger extended kinship networks, or
the community (Carter & Murdock, 2001; Sue &
Sue, 2003). Clarifying the parents’ definition of ‘the
family’ also is critical for identifying sources of sup-
port and stress within the family system. Moreover,
the evaluator’s awareness and openness to diverse
definitions of ‘the family’ is essential for building a
positive working alliance with the family. Although a
thorough evaluation of the caregiving context would
include assessments that target multiple dimensions
of family system functioning, a review of family
functioning measures is beyond the scope of this
paper.
The reciprocal nature of parent–child interac-
tions. Both experimental and correlational studies
demonstrate the inter-relatedness of child behavior
and the parenting context. For example, Acker and
O’Leary’s (1996) experimental manipulation of the
behavior of mothers of typically developing toddlers
reveals how variations in parenting strategies can
amplify negative behaviors, such as negative affect
and demanding maternal attention. This study
demonstrated increases in child negativity and
demanding behavior when mothers responded
inconsistently to child negative behavior, alternating
between positive feedback and reprimands. Consis-
tent with this finding, Shaw and his colleagues
reported that boys whose mothers were both reject-
ing and ‘responsive’ evidenced higher externalizing
scores than boys whose mothers were rejecting and
unresponsive (Shaw et al., 1998). The transactional
or reciprocal nature of patterns in parent–child
relationships extends over time and also must be
acknowledged in considering child social-emotional
behaviors in context (Sameroff, 2000). It is quite
likely that ‘goodness of fit’ plays an important role,
with child characteristics, such as infant tempera-
ment, combining with parental perceptions and
parenting styles to minimize or increase risk for later
psychopathology (Seifer, 2000).
Methods for assessing the parent–child relation-
ship. A number of procedures and coding schemes
have been developed to assess different aspects of
the parent–child relationship. Coding schemes vary
with respect to the number of different types of
contexts that are assessed (e.g., feeding interaction,
free play, teaching, laboratory or in-home environ-
Infant–toddler assessment 115
ment), the level of inference required for making
ratings, and the number of behaviors or qualities
that are coded. Some of the most widely used
measures are described below.
The Nursing Child Assessment Satellite Training
(NCAST) Teaching Scale (newborn to 36 months) and
Feeding Scales (newborn to 12 months) include
structured interactions that are coded for 149 dis-
tinct behaviors (Barnard, 1979). Behaviors are coded
reliably in a presence/absence format observing an
interaction live or coding from videotape with the
opportunity to replay interactions.
The Clinical Problem-Solving Procedure, developed
by Crowell and Feldman (1988), is based on the ‘tool-
use task’ (Matas, Arend, & Sroufe, 1978). The ex-
aminer selects tasks that he/she believes the child is
not capable of completing independently. The parent
is then provided with a varied set of common toys
and activities and instructed to play with her child.
The activities assigned are increasingly difficult, and
the last two are technically beyond the child’s
developmental capacities. This coding scheme has
been used in clinical and research applications
(Crowell & Fleischmann, 1993).
The Emotional Availability Scale (EAS) 3rd edition
(Biringen, Robinson, & Emde, 1998) involves global
ratings of parental sensitivity, structuring, intru-
siveness, and hostility and child responsiveness and
involvement with the parent that are based on
watching a parent–child interaction. Dyadic emo-
tional availability emphasizes both caregiver and
child emotional openness and communication within
dyadic interactions. Emotional availability is a
dimensional construct that captures the quality of the
mother–infant interaction by focusing on both
maternal and infant characteristics in a relational
context. Maternal sensitivity, structuring, non-
intrusiveness and lack of hostility facilitate the in-
fant’s ability to regulate emotion and behavior, and to
respond to the mother and others in a responsive and
involving manner (Biringen, 2000; Biringen &
Robinson, 1991; Robinson, Emde, & Korfmacher,
1997).
The Parent–Child Early Relational Assessment
(PCERA) focuses on the parent and child’s experience
of the relationship, the affective and behavioral
characteristics that each brings to the interaction,
and the quality or tone of the relationship (Clark,
1985; Farran, Clark, & Ray, 1990). Twenty-nine
parent-focused constructs, 30 child-focused con-
structs, and 8 dyadic constructs are rated during
four 5-minute segments that include feeding, a
structured situation in which the mother shows the
child how to accomplish a challenging task, free play,
and a brief separation. The PCERA identifies areas of
strength and areas of concern in the parent, the child,
and the dyad. Internal consistency of factors, inter-
rater reliability and predictive and discriminant va-
lidity are adequate (Clark, 1999; Clark, Hyde, Essex,
& Klein, 1997; Clark, Paulson, & Conlin, 1993).
 116 Alice S. Carter, Margaret J. Briggs-Gowan, and Naomi Ornstein Davis
The contexts of race, ethnicity and culture
When evaluating the caregiving context, it is im-
portant to distinguish between culture, race, and
ethnicity. Culture is the term used to describe
shared values, beliefs, and practices that are trans-
mitted across generations within a group (cf., Pin-
2 derhughes, 1989; Tomlinson-Clarke, 1999). From a
population genetics perspective, there are no dis-
crete boundaries between racial groups (Marshall,
1998; Rosenberg et al., 2002). While there are small
differences between populations, most of the vari-
ability across all humans comes from within popu-
lation differences (Marshall, 1998; Rosenberg et al.,
2002). Consistent with this, Suyemoto and Dimas
(2003) argue that ‘race is a socially constructed
concept of categorization and distinction within so-
cial relationships based on physical characteristics.’
Ethnicity is used to denote a particular kind of cul-
ture, which is usually associated with a common
geographic region, or national origin (Atkinson,
Morton, & Sue, 1998; Pinderhughes, 1989; Sue &
Sue, 2003). Increasingly, families are multi-ethnic,
cultural, and racial. The number of multi-ethnic
children has steadily increased in the United States
over the past 30 years (US Bureau of the Census,
2000). When evaluating a multi-ethnic child, it is
important to recognize that the parents of multi-
ethnic children are often criticized by others for
engaging in cross-cultural relationships and face a
distinct set of parenting challenges (Gibbs, 1987;
Root, 1990; Rosenblatt, 1999).
Scholars who study cultural influences on devel-
opment advocate that cultural beliefs, values, and
practices should be a central focus of assessments
of young children (Betancourt & Lopez, 1993;
Christensen, Emde, & Fleming, in press; Garcia-
Coll & Magnuson, 2000). Moreover, it is critical to
recognize that culture is not a static entity, but is
dynamic and responsive to the settings and condi-
tions to which the family must adapt (Christensen
et al., in press). Thus, the day-to-day routines and
household practices through which culture is
maintained within the family and transmitted to the
child are influenced by factors such as immigration,
economic conditions, and exposure to other cultural
groups. In advocating that researchers and clini-
cians attend to the influence of culture, race, and
ethnicity, we recognize that this often involves
acquiring training in culturally competent practices.
In addition to openness to diversity and awareness
of varying cultural practices, researchers and cli-
nicians must engage in a process of self-awareness
to avoid biases that could lead to over- or under-
pathologizing the child or family practices. Cultural
proficiency is central to gathering reliable and valid
information. For an extensive discussion of cultural
competence see the American Psychological
Association (2002) Guidelines on Multicultural
Education, Training, Research, Practice and
Organizational Change (http://www.apa.org/pi/
multiculturalguidelines).
DSM-IV Outline for Cultural Formulation. Relevant
to work with young children, Christensen and col-
leagues (in press) offer recommendations for adapt-
ing the DSM-IV Outline for Cultural Formulation for
young child assessment. These recommendations are
relevant for diagnostic evaluations, as well as in
planning screening and more comprehensive
dimensional assessments of young children’s social-
emotional development and problem behaviors. For
example, when the individual being assessed is an
infant or toddler, Christensen et al. (in press) place
the focus on the parents’ cultural reference group
(e.g., ethnic or cultural reference group, identification
with culture of origin and dominant culture, language
ability, use, and preference) and highlight the ‘par-
ents’ intentions for raising the child with respect to
the culture of origin and the dominant culture.’
Concerns raised with respect to cultural identity may
include issues of multi-cultural identification and the
possible inter-generational pressures and conflicts
that can arise when families are multi-cultural.
The DSM-IV Cultural Formulation also considers
whether cultural explanations of the individual’s ill-
ness differ from the dominant culture. For infants
and toddlers, behaviors considered problematic
within the dominant culture may not generate con-
cern within the family. Christensen et al. (in press)
recommend talking with families about the following:
(1) perceptions of the child’s difficulties or distress;
(2) how the child’s behavior is viewed relative to other
child behavior in their cultural group; (3) cultural
explanations for the child’s difficulties or distress;
and (4) parental experiences with and preferences for
treatment.
Another area outlined by the DSM-IV Cultural
Formulation addresses cultural elements of the
relationship between the individual (or parents/
caregivers) and the clinician. Also relevant to the
assessment context, cultural differences between the
evaluator and the child’s parents may interfere with
gathering reliable and valid data about child and
family functioning. Communication barriers that
stem from differences in language or contextual
understanding of behaviors and emotions must be
examined and efforts made to minimize miscom-
munication.
Of interest, neither the DSM-IV Cultural Formu-
lation nor the Christensen and colleagues adapta-
tion address distinctions between culture and race.
Yet, families of color face unique challenges associ-
ated with societal racism and stereotyping. Thus, the
caregiving context may be influenced by race, inde-
pendent of the contribution of culture and ethnicity
(Suyemoto, personal communication, June 10,
2003). For this reason, to fully understand the
caregiving context it may at times be necessary to
assess parents’ perceptions of racism.

Cultural issues in measurement/assessment
tools. Although the DSM-IV Cultural Formulation
emphasizes barriers to developing a clinical rela-
tionship that facilitates diagnosis and treatment,
these issues also must be considered with respect to
assessment tools. It is not sufficient to employ a
measure that has been translated into the target
population or client’s native language, because the
translation may not be appropriate for the popula-
tion under study or the family seeking treatment. For
example, in our experience in developing the Span-
ish translation of the ITSEA, a sample item, ‘uses a
pacifier,’ was initially translated by a Spanish spea-
ker of Puerto Rican descent. When researchers on
the West Coast prepared to employ the measure with
a predominantly Mexican American population, this
item was deemed to have a sexualized meaning that
was clearly inappropriate for this population.
Although translation and back-translation has
traditionally been held as a standard, it may not be a
sufficient practice (cf., van de Vijver & Leung, 1997).
Instead, using focus groups and/or pilot testing with
the target population is highly recommended to
avoid miscommunication. In addition, because it is
rare to obtain appropriate within ethnic group re-
liability and validity data, investigators who are
working with minority populations are encouraged to
report internal consistency statistics when present-
ing findings. It is not appropriate to assume that the
internal consistency or factor structure obtained in a
dominant culture population will be comparable
when a scale is employed with ethnic/racial minority
groups. In clinical settings, individual problem and
competence items that parents endorse should be
reviewed in order to understand the threshold that
parents are using to determine whether or not a
behavior is ‘Somewhat True’ or ‘Often True.’ In
addition, the affective valence that is attributed
to the behavior and the cultural meaning of the
behavior, if any, must be part of the initial dialogue
with the family. Depending on the outcome of such
discussions, the clinician must be prepared to
determine and report whether a particular measure
is culturally invalid.
A study by McCain, Kelley, and Fishbein (1999)
highlights the importance of attending to possible
response differences across ethnic/racial groups.
They explored response patterns by Black/African
Americans and Whites on the Toddler Behavior
Symptom Inventory, a parent-report measure of
problem behaviors. Of interest, although there were
no differences in the reported frequencies of problem
behaviors, Black/African American parents were
more likely to be concerned about their children’s
problem behaviors than White parents. Unfortu-
nately, given the lack of multivariate examination of
this finding, it is not possible to attribute this finding
to ethnicity/race. It is equally plausible that the
observed difference between Black/African Amer-
ican and White parents was a function of class or
Infant–toddler assessment 117
education level. Nonetheless, this interesting finding
underscores the importance of taking race/ethnicity
into consideration.
The context of risk – cumulative risk factors
In addition to examining the child’s developmental
and caregiving context, broader contextual features
that may support or impede the child’s adaptive
development (e.g., poverty, exposure to community
violence, recent traumatic events, low parental edu-
cation, limited social support) should be examined.
It is now clear that an accumulation of environ-
mental risk factors within and beyond the family
system has a deleterious impact on young children’s
development (cf., Sameroff, Seifer, & McDonough, in
press). Beginning with Rutter’s pioneering research
on the Isle of Wight (Rutter, Tizard, Yule, Graham, &
Whitmore, 1976; Rutter, 1989), a large number of
studies have described both the unique and cumu-
lative impact of ecological risks, often including
family poverty as one of a number of such risks, on
children’s development (e.g., Sameroff, Bartko, &
Baldwin, 1998; Sameroff & Chandler, 1975). Gen-
erally, this research has employed cumulative risk
models, indicating that as the number of risk factors
increases, child outcomes worsen (Hooper, Burch-
inal, Roberts, Zeisel, & Neebe, 1998; Liaw & Brooks-
Gunn, 1994; Sameroff, Seifer, Baldwin, & Baldwin,
1993; Shaw & Emery, 1988). Risk factors can be
aggregated across the child, family, and community
levels of the Bronfenbrenner (1986) bio-ecological
model. In contrast to assessments of developmental
level and parent–child relationships, which reflect
dynamic developmental processes, cumulative risk
indices include both static characteristics of family
members (e.g., minority status) and factors that may
be amenable to intervention (e.g., elevated depres-
sive symptoms, limited social support).
Developmental context
Children’s social-emotional development and psy-
chopathology should be evaluated within the context
of cognitive and linguistic development, as well as
with attention to any physical or health conditions
that may be present (Sparrow, Carter, Racusin, &
Morris, 1995). Anna Freud (1966) wrote eloquently
about the need to evaluate multiple lines of devel-
opment and to attempt to understand the manner in
which development along one line may set con-
straints on growth in other developmental domains.
As highlighted by Cicchetti and Sroufe’s (1976) work
on the development of young children’s humor,
expectations for social-emotional development must
be based within the context of the child’s overall
cognitive development or mental age. Although all
developmental domains (e.g., cognition, language,
gross and fine motor functions, sensory capacities)
deserve attention, language delay is the most typical
118 Alice S. Carter, Margaret J. Briggs-Gowan, and Naomi Ornstein Davis
reason for parents to raise concern about their chil-
dren’s development (Horwitz, Gary, Briggs-Gowan, &
Carter, in press). Young children with language delay
are at very high risk for social-emotional and beha-
vior problems (Beitchman, Wilson, Brownlie, Wal-
ters, & Lancee, 1996; Horwitz et al., 2003; Irwin,
Carter & Briggs-Gowan, 2002; Rescorla, 2000) and
all young child mental health evaluations should, at
a minimum, include screening for cognitive and
language delay. When results of screening indicate
the possible presence of social-emotional/behavioral
problems and/or cognitive/language delays it is
important to conduct more comprehensive stan-
dardized assessments of developmental level.
Screening for early problems
In recent years, there has been growing recognition
of the importance of early detection of not only
developmental delays, but also social-emotional
and/or behavioral problems (American Academy of
Pediatrics, 2001; US Public Health Service, 2000).
Indeed, the American Academy of Pediatrics (2001)
recently recommended routine screening by pediat-
ricians to enhance efforts to identify early social-
emotional problems. Of note, there is evidence that
screening in pediatrics is both feasible (Baird et al.,
2000; Jellinek et al., 1999) and effective in improv-
ing rates of referral for mental health services (Mur-
phy et al., 1996). Early detection efforts have been
advanced by public policies that facilitate early
intervention efforts, most notably Part C of The
Individuals with Disabilities Education Act Amend-
ments of 1997 (IDEA; Public Law No. 105-17), which
mandates intervention services for children from
birth to age 3 years who have delays in cognitive,
language, motor, and social development. Part C also
provides discretionary services for young children
with emotional/behavioral problems that may place
them at risk for later developmental problems. De-
spite such policy advances, many early-emerging
social-emotional problems go undetected and,
therefore, unaddressed by service systems. High-
lighting the need for enhanced screening efforts, re-
cent research in a representative healthy birth
cohort of an urban and suburban sample revealed
that only 8% of 1- and 2-year-olds with parent-
reported social-emotional/behavioral problems were
receiving services (Horwitz et al., in press).
We advocate the use of multi-gating, or multi-stage
screening procedures as a cost-effective means for
screening large groups of children (Loeber, 1990;
Lochman and the Conduct Problems Prevention Re-
search Group, 1995). The first step in such a process
involves utilizing a brief and relatively inexpensive
screening assessment tool to identify children at
elevated risk. This first step can ideally occur in pe-
diatric offices at the time of well-child visits. Children
who are identified as at elevated risk based on an
inexpensive screener can then be referred for a sec-
ond, more comprehensive screening. Moreover, first
stage screening need not be a single snapshot or
static assessment. Indeed, an ideal screening strat-
egy would be dynamic (Squires, Bricker, & Potter,
1997), with children screened at multiple well-child
visits over time. In this dynamic scenario, referrals
for a second or third stage screening can occur after
an initial positive screen or after it is clear that the
problematic behaviors persist over time. The second
stage of screening might involve a longer parent-
report instrument accompanied by questions regar-
ding (1) the parent’s degree of concern about the
child’s behaviors and (2) presence of any impairment
or interference in daily activities as a function of the
child’s social-emotional behaviors, temperament,
or special needs (Briggs-Gowan et al., 2001). The
meaning of the child’s behavior and cultural con-
siderations are central foci of the comprehensive
second-stage assessment. Depending on available
resources, the third stage of screening would involve
observations, collateral informants, and/or referral
for more intensive diagnostic evaluation. Ideally, this
third stage evaluation would be conducted at a site
that can also provide intervention services. Of note,
the decision to proceed to the second or third stage of
screening could be based on a number of parent
report indices, including parent’s indication of con-
cern, the profile of scores obtained from a longer
second-stage parent report instrument, a high score
on a cumulative risk factor score, and/or the pres-
ence of developmental or family disruption.
Screeners used for widespread detection efforts
should have certain characteristics. For example,
they should be brief, easy to administer, score and
interpret, and should demonstrate acceptable reli-
ability and validity (Eisert et al., 1991; Jellinek &
Murphy, 1988). Ideally, screeners should be simple
enough that most parents can complete them in-
dependently (Glascoe, 2000), thus reducing expenses
associated with staff time (Carter, 2002). Further,
with advances in technology, parents may be able
to complete screeners on hand-held computers to
facilitate ease of both administration and scoring
(Carter, 2002). Finally, it is crucial that screeners
provide information that is both developmentally
appropriate (Glascoe, 2000; Rescorla & Achenbach,
2002) and clinically useful (Carter, 2002).
Another important feature of a screener, related to
its validity, is its ability to maintain a balance
whereby a sufficient proportion of children with
problems are detected while maintaining an accep-
table rate of false positives. In developing maximally
useful and cost-effective screening tools, there is
inherent tension about where to set the scoring
threshold for identifying a child as a screen positive
(versus negative). If the threshold is too high, then
too few true ‘cases’ (with ‘case’ defined, for example,
on the basis of meeting criteria for a psychiatric
disorder or having significant functional impair-

ment) will screen positive (i.e., the screen will have
low sensitivity). Yet, the screener will likely have high
‘specificity,’ meaning it will identify a low proportion
of ‘non-cases’ as screen positives. In contrast, if the
threshold is set too low, sensitivity will be high, but
specificity will be low, potentially flooding the service
system with unnecessary costs for assessing false
positives. Thus, it is important to achieve a balance
between identifying a sufficient proportion of ‘cases’
to effectively improve early detection, while minim-
izing false positives. To meet these competing con-
straints, Meisels (1989) has suggested that
screening tools should have sensitivity and specific-
ity of 80% or higher.
Moreover, consistent with longer dimensional
assessment instruments, screeners should have
adequate psychometric properties with respect to
reliability and validity. In evaluating the level of
acceptability of reliability and validity statistics,
several criteria, recommended by Cicchetti, are em-
ployed. Sensitivity and specificity statistics and lev-
els of agreement may be judged by the following
criteria: 90% to 100% ¼ excellent; 80% to 90% ¼
good; 70% to 79% ¼ fair; and less than 70% ¼ poor
(Cicchetti, Volkmar, Klin, & Showalter, 1995). In
measuring internal consistency of scales, Cron-
bach’s alpha may be evaluated as follows: .90 to
1.0 ¼ excellent, .80 to .89 ¼ good, .70 to .79 ¼ fair,
and less than .70 ¼ poor (Cicchetti, 1994). For
Kappa, Weighted Kappa, and Intraclass Correlation
Coefficients, 1.0 to .75 ¼ excellent, .60 to .74 ¼
good, .40 to .59 ¼ fair, and less than .40 ¼ poor.
Pediatric settings are well suited to the task of
detecting social-emotional and behavior problems
(American Academy of Pediatrics, 2001; Regier,
Goldberg, & Taube, 1978). For example, given stan-
dard immunization schedules in early childhood,
pediatricians have frequent and routine contact with
many young children and their families. In addition,
families with children who have social-emotional/
behavioral problems tend to utilize pediatric services
more than other families (Zuckerman, Moore, & Glei,
1996) and are therefore particularly likely to be in-
cluded in routine screening. Furthermore, one study
indicated that parents who discussed their chil-
dren’s social-emotional/behavioral problems with
their pediatrician were three times more likely to
obtain mental health services for their children than
those who did not discuss these issues with their
pediatrician (Briggs-Gowan, Horwitz, Schwab-Stone,
Leventhal, & Leaf, 2000). Further, including routine
screening of social-emotional/behavior problems is
one way to inform parents that these behaviors are
an appropriate topic of conversation in the pediatric
office. Given the vital role that the pediatrician can
play in children’s mental health and evidence that
screening in pediatrics is both feasible (Baird et al.,
2000; Jellinek et al., 1999) and effective in improv-
ing referral rates (Murphy et al., 1996), routine
screening may play an important role in ensuring
Infant–toddler assessment 119
that the needs of young children with early-emerging
difficulties are addressed.
Measurement of developmental issues
To aid in the selection of tools for assessing devel-
opmental level and language functioning, several
commonly used tools that have adequate psycho-
metric properties are discussed in the following
section. Both brief screening tools, parent report
measures, and comprehensive, standardized
assessments that are administered directly to the
child are reviewed (see Tables 1 and 2).
Screening tools for assessing developmental issues
Three screeners for measuring possible develop-
mental problems are reviewed. As evident in the
descriptions below, these measures vary signific-
antly in terms of length (from 30 items to 100
items), method of administration (from parent report
to administered by a paraprofessional), domains
covered, and item density within a particular
domain.
The Ages and Stages Questionnaires (ASQ): A
Parent-Completed, Child Monitoring System (Bricker
& Squires, 1999) is a widely used, first stage
screening measure for children 4 to 60 months of
age, with different forms dependent on the age of the
child (Table 1). The 30 question ASQ addresses five
domains of development (Communication, Gross
Motor, Fine Motor, Problem Solving, and Personal-
Social). To aid parents in completing the screener,
some questions have pictures depicting the child
demonstrating a particular skill. The ASQ can be
completed in 10 to 20 minutes. Two-week test–retest
reliability of screening status is adequate, with 94%
agreement. Validity relative to standardized assess-
ments of developmental level is acceptable (84%
agreement overall, 72% sensitivity overall, specificity
from 81% to 92%).
The MacArthur Communicative Development
Inventory Short Form (CDI) (Fenson et al., 1993;
Fenson et al., 2000a, b) is a parent-report vocabu-
lary checklist that is designed as a screener for
assessing productive vocabulary in 12- to 36-
month-old children (Table 1). There are two ver-
sions, depending on the age of the child. The Infant
form is intended for 8 to 18 months, whereas the
Toddler form spans from 16 to 30 months of age.
Each form contains a list of vocabulary words. To
complete the Infant form, the informant indicates
whether the child (1) understands each word or (2)
says each word. On the Toddler form, the inform-
ant indicates simply whether the child says each
word. Scores are calculated as sums. The Mac-
Arthur CDI has demonstrated high internal consis-
tency and good test–retest reliability in measuring
productive vocabulary in toddlers. In addition,
 120
Alice S. Carter, Margaret J. Briggs-Gowan, and Naomi Ornstein Davis
Table 1 Selected cognitive and language screening instruments

Ages and Stages Questionnaires MacArthur Communicative Brigance Screens – Infant

(ASQ) (Bricker & Squires, Development Inventories–Short Form and Toddler Screen (Brigance & Language Development
1989, 1999) (Fenson et al., 2000b) Glascoe, 2002) Survey (Rescorla, 1989)

Age range 4 months to 5 years (questionnaires 8–18 months (infant form) Birth–11 months (infant form) 18–35 months
for 2–6-month age groupings) 16–30 months (toddler form) 12–23 months (toddler form)
Respondent Parent or caregiver Parent or caregiver N/A (administered) Parent or caregiver
Number of items 30 items 89 words (infants) 85 items (infant form) 310 words
100 words (toddlers) 83 items (toddler form) Parent report of child’s
5 longest phrases/sentences
Administration time 10–20 minutes 10 minutes 10 minutes 10 minutes
Skills/Domains assessed Communication Language Fine Motor Expressive Language skills
Gross Motor and communication skills Gross-Motor
Fine Motor Receptive language
Problem Solving Expressive language
Personal-Social Self-help skills
Social-emotional skills
How items are scored Items are rated as to whether Infant form: check if child Skills are directly observed One point for each word that
the child demonstrates ‘understands word’ and elicited by assessor the child says. The child’s
the behavior: Yes, sometimes, or ‘says word’ and parent. mean length of phrases
or not yet Toddler form: check Points are given for skills is also calculated.
if child ‘says word’ that are demonstrated.
Scoring/Cut-points Cut-points indicate low risk Cut-points set at lowest 10th Yields a nonverbal score For children 24-months
and high risk (high risk suggests percentile based on standardization and a communication score or older, the cut-point
need for referral) sample by age and sex groupings is fewer than 50 words
or no word combinations
Language and cultural Available in Spanish, French, Available in Spanish Available in Spanish Available in Spanish/English
validity and Korean versions
Level of difficulty 4th to 6th grade reading level Reading level not reported, N/A 5th grade reading level
to complete with illustrations but simple in format
to assist in clarifying item content
Level of training Staff or paraprofessionals Professionals score Paraprofessionals conduct Nonprofessional staff may
to administer can score in 1 to 5 minutes observations administer
 Infant–toddler assessment 121

Table 2 Selected cognitive and language assessments

Mullen Scales Bayley Scales of Infant Preschool Language Scale,

of Early Learning Development (BSID-II) 4th edition (PLS-4) (Zimmerman,
(MSEL) (Mullen, 1995) (Bayley, 1993) Steiner, & Pond, 2002)

Age range Birth to 68 months 1–42 months Birth to 71 months

Description Individually administered;
Identifies strengths and
weaknesses across domains;
Assesses school readiness
Administration time 15 min. (l year)
25–35 min. (3 years)
40–60 min. (5 years)
Skills/Domains Gross Motor
assessed Visual Reception
Fine Motor
Expressive Language
Receptive Language
Scoring 5 Scales: T-scores, percentile
ranks, age equivalents
Early Learning Composite:
standard scores, percentile
ranks
Language and cultural The standardization was
validity based on census data
in 1987–1989, and
controlled for race,
SES/parent occupation,
gender, community size,
age, geographic region.
Level of training Graduate training and
to administer experience in infant
assessment
Individually administered;
Assists in diagnosing
developmental delay;
Useful for planning
interventions
1 hour
Mental scales
Motor scale
Behavior rating scale
Standard scores:
Mental Development Index
Psychomotor Development Index
Renorming sample was stratified
on age and sex and on region,
race/ethnicity, and parental
education.
PhD-level training and relevant
training in assessment
Assesses expressive
and receptive language;
Caregiver Questionnaire
allows integration of results
with report of child’s typical
communication at home
20–45 minutes
Auditory Comprehension
Expressive Language
Standard scores, percentile
ranks, and language age
equivalents for: Total Language;
Auditory Comprehension;
Expressive Communication
A Spanish version of the PLS-4
normed on Spanish-speaking
children living in the USA.
Test items and art are
considered appropriate
for children from different
SES and cultural/regional
groups.
Master’s-level training and
relevant training in assessment

statistical cut-points reflecting the lowest 10th
percentile on the MacArthur CDI (for a child’s age
and sex) have been established in a national
standardization sample. As the standardization
sample was predominantly white and most
respondents had completed high school, results
should be interpreted cautiously if used with fam-
ilies with limited education or from ethnic minority
backgrounds.
The Brigance Infant and Toddler Screen (Brigance
& Glascoe, 2002) is a recent downward extension of
the Brigance screens that have been in used with
older children (Table 1). This screening tool is
administered by a paraprofessional. There are sep-
arate Infant and Toddler versions, with different
items depending on child age. The infant screen,
designed for children from birth to 11 months, con-
tains 85 items. The toddler screen, developed for 12-
to 23-month-olds, contains 83 items. Both versions
include items for assessing fine and gross motor
skills, receptive and expressive language skills, self-
help skills, and social-emotional skills. The screen-
ing is conducted by a paraprofessional who works
with both the child and the parent to determine
whether skills are present. The screening score is
based on skills observed during the assessment
session. This measure has demonstrated adequate
reliability and validity.
The Language Development Survey (LDS) (Rescorla,
1989) is a parent-report vocabulary checklist that
was developed as a simple, inexpensive screening tool
to identify language delay in toddlers. The measure is
designed for use with children ages 18–35 months,
but the cut-points for determining language delay are
best validated for children 24-months and older. A
parent or caregiver indicates which words their child
says on the 310-word checklist. If the child uses
phrases or sentences, the parent is asked to offer 5
examples of the child’s longest or best phrase or
sentence. A total vocabulary score is calculated based
on the number of words that the parent endorses.
In addition, a mean phrase length score is calculated
by dividing the total number of words in the valid
phrases by the number of valid phrases reported. The
measure takes 10 minutes to complete and does not
require professional training for administration or
scoring. The LDS has excellent reliability of the
vocabulary section and good reliability for the mean
length of phrases. In addition, the measure has
demonstrated good sensitivity and specificity in
predicting children with expressive language delay
(Rescorla & Achenbach, 2002).
122 Alice S. Carter, Margaret J. Briggs-Gowan, and Naomi Ornstein Davis
Standardized developmental assessments
In this section, two commonly used standardized
assessments that address the full range of develop-
ment and one standardized assessment of language
level are reviewed. In-depth details about the psy-
chometrics of these tools are available in published
manuals.
The Mullen Scales of Early Learning (MSEL; Mul-
len, 1995) is an individually administered assess-
ment that can be used with children from birth
through 68 months of age. The Mullen identifies
children’s strengths and weaknesses in 5 domains of
functioning (expressive language, receptive lan-
guage, visual reception, fine motor, and gross mo-
tor). T-scores are generated along with percentile
ranks and age equivalents to facilitate comparison of
children’s developmental level to their age-matched
peers. In addition, an Early Learning Composite
standard score is calculated based on the four cog-
nitive scales. For older children, Mullen scores can
be helpful in assessing school readiness. The Mullen
Scales were standardized on a nationally represen-
tative sample that includes more than 1,800 chil-
dren from 4 geographic regions in the United States.
The normative sample contained equal numbers of
boys and girls and closely matched US population
estimates for race/ethnicity, community size, and
socioeconomic status. The Mullen has adequate
reliability and validity.
A second commonly used cognitive assessment
tool for infants and toddlers is the Bayley Scales of
Infant Development (BSID-II; Bayley, 1993). This
test can be used with children ages 1 to 42 months
and is useful in assessing developmental delays
across a range of mental and motor functioning
including cognitive, language, personal-social, fine
motor, and gross motor skills. Two standard scores
are computed: a Mental Development Index and a
PsychoMotor Development Index. A behavior rating
scale that assesses children’s behavior during the
assessment process is also useful for interpreting
the Mental Development and Psychomotor Devel-
opment Indices calculated based on test perform-
ance. The Bayley II was normed on a sample of
1,700 children who were grouped by age, sex, US
geographic region, race/ethnicity, and parental
education.
Whereas the Mullen and the Bayley are designed
to assess children’s development more broadly in
terms of cognitive, motor, and language functioning,
the Preschool Language Scale, 4th edition (PLS-4;
Zimmerman, Steiner, & Pond, 2002) specifically
measures children’s expressive and receptive lan-
guage capabilities. Used with children from birth to
71 months, the PLS-4 is an individually adminis-
tered test of comprehension and spoken language.
An additional Caregiver Questionnaire allows the
examiner to integrate results of the formal assess-
ment with the caregiver’s report of the child’s typical
communication style in other settings. Standard
scores, percentile rank, and age equivalents all
facilitate comparison of children’s performance to
their age matched peers. The authors report that the
test content is considered appropriate for children
from different cultural, regional, and socioeconomic
groups. In addition, a Spanish version of the PLS-4
has been created and normed on almost 1,200
Spanish-speaking children living in the United
States.
Measurement of social-emotional and behavioral
problems, competencies, and psychopathology
In this section, widely used and newly developed,
promising measures of social-emotional/behavioral
problems, social-emotional competence, and psy-
chopathology are discussed. In general, social-
emotional development has received little attention
in developmental assessments, as evidenced by the
fact that traditional developmental tests such as the
Mullen and the Bayley do not assess this construct.
Similarly, most past research/clinical work/
assessment tools have focused on assessments of
problem behaviors. Nonetheless, it is also useful to
gather information about children’s social-emo-
tional and behavioral competencies. In infancy and
toddlerhood, a wide array of self- and social com-
petencies can be assessed through parent report
and direct observations (Briggs-Gowan & Carter,
1998; Carter et al., 2003; Houck, 1999; Sroufe,
1990; Stipek, Recchia, & McClintic, 1992). Gather-
ing information about social-emotional and beha-
vioral competencies can serve several purposes.
First, the presence of a delay in this domain is a
risk factor for the emergence of behavior problems
and psychopathology (e.g., Carter, 2002; Cicchetti
& Cohen, 1995; Denham & Holt, 1993). Compet-
ence in stage-salient tasks increases the likelihood
of later competence (Houck, 1999; Sameroff et al.,
1998) and minimizes the emergence of new and
maintenance of existing maladaptive patterns of
behavior (Carter, 2002; Keenan & Shaw, 1997;
Masten & Coatsworth, 1995, 1998). Second, as-
sessing social-emotional and behavioral compe-
tence provides one avenue for evaluating the
relative degree of impairment associated with extant
problem behaviors (Briggs-Gowan et al., 2001). To
the extent that problem behaviors co-occur with
delays in the acquisition of stage-salient compet-
encies, concern for the child’s overall development
is raised. Third, including questions about both
positive and negative aspects of the child may
minimize parental response biases (Briggs-Gowan &
Carter, 1998; Carter, 2002). Finally, in clinical
evaluations of young children, assessing social-
emotional and behavioral competencies may facilit-
ate the design of interventions that capitalize on
children’s strengths.

Screening tools for assessing social-emotional and
behavioral problems and competencies
In recent years, the number of screening tools
available for assessing social-emotional functioning
in the infant–toddler period has grown (see Table 3).
However, many screeners now available focus on a
specific area of social-emotional adjustment (e.g.,
behavior problems) and do not provide comprehen-
sive coverage of both problems and competencies.
For example, the 36-item Eyberg Child Behavior
Inventory (Colvin & Eyberg, 1999; Eyberg, 1980;
Eyberg & Pincus, 1999), developed for 2 1/2- to 11-
year-olds, focuses on conduct problems, aggression
and attention and has demonstrated acceptable re-
liability and validity. Similarly, the 40-item Toddler
Behavior Screening Inventory (TBSI) (Mouton-
Simien, McCain, & Kelley, 1997) measures behavior
problems in 1- to 3-year-olds. The TBSI has shown
acceptable sensitivity in detecting children referred
for psychological services by their pediatrician
(McCain et al., 1999).
Early Childhood Assessment (DECA; LeBuffe &
Naglieri, 2003) takes a strength-based approach to
screening. The 37-item DECA, developed for 2- to
5-year-olds, includes three protective factor scales
(Initiative, Self-control, and Attachment) and a
behavioral concerns scale. Parent and childcare
provider versions are available. In addition, a com-
panion guide that provides strategies for intervening
based on the results of the DECA is available for
helping children in early intervention settings. The
DECA has acceptable test-retest and inter-rater
reliability. In a study that compared 95 preschool-
aged children with emotional and behavior problems
to 86 socio-demographically matched community
children with no emotional or behavioral concerns,
the two groups were significantly different, in ex-
pected directions, on each of the scales that com-
prise the DECA. In the same study, the protective
factor scale and the behavioral concerns scale
achieved sensitivity of 67% and 78% in the problem
group and 71% and 65% specificity, respectively
(LeBuffe & Naglieri, 2003). As neither measure
meets recommended guidelines, it may be premature
to use the DECA as a screener for social-emotional/
behavior problems. However, the DECA may be a
useful brief measure of children’s strengths and
problems.
The Ages & Stages Questionnaire–Social-Emotional
Version (ASQ-SE; Squires, Bricker, & Twombly,
2002a) is a promising screener for measuring social-
emotional and behavioral problems from birth to
5 years of age. This measure was developed as a
companion to the ASQ developmental screeners
(described in Table 1). It has demonstrated accept-
able test–retest reliability, as well as sensitivity in
detecting children with developmental delay and/or
social-emotional diagnoses (Squires, Bricker, &
Twombly, 2002b). Scoring of the ASQ-SE is fairly
Infant–toddler assessment 123
simple and yields cut-point scores indicating poss-
ible problems in the social-emotional domain.
The Brief-Infant-Toddler Social-Emotional Assess-
ment (BITSEA; Briggs-Gowan, 2000; Briggs-Gowan,
Carter, Irwin, Wachtel, & Cicchetti, in press) is a 42-
item measure for identifying social-emotional/be-
havioral problems and delays in competence in 1- to
3-year-old children. The BITSEA has both social-
emotional/behavioral problem and competence in-
dices. It has demonstrated acceptable test–retest
reliability and inter-rater reliability. In addition,
concurrent validity has been shown between BITSEA
Problems and CBCL Internalizing and Externalizing
Scores, as well as evaluator ratings of child problem
behaviors during a testing situation. Further, BIT-
SEA Competence has shown low to modest correla-
tions with evaluator ratings of competence. The
BITSEA cut-points have demonstrated high sensi-
tivity (80–95%) in detecting children with social-
emotional/behavioral problems according to the
longer CBCL/1.5-5, as well as children with high
problem scores and/or low competence scores on the
more comprehensive ITSEA (80% sensitivity), while
maintaining acceptable specificity. In addition, re-
cent work indicates that the BITSEA is highly sen-
sitive to autism spectrum disorders (Carter, Irwin,
Skuban, & Briggs-Gowan, 2001). Finally, pre-
liminary results from a longitudinal birth cohort
suggest that children who screen positive on the
BITSEA during toddlerhood are at moderate to high
risk for persistent language/learning and/or social-
emotional problems according to Kindergarten
teacher reports (Briggs-Gowan & Carter, 2003).
It is important to note that in the infant–toddler
period, it may be premature to recommend imple-
menting routine screening. Although screening tools
such as the BITSEA and ASQ-SE show promise,
their clinical validity has yet to be established. It is
therefore important to document that these tools are
sufficiently sensitive to clinically significant social-
emotional/behavioral problems (detecting a min-
imum 80% of cases), yet maintain false positive rates
that are low enough (20% or lower) that service sys-
tems are not overwhelmed unnecessarily. To address
this need, current research undertaken by Briggs-
Gowan and her colleagues is examining the clinical
validity of both the ITSEA and the BITSEA, in
relation to consensus psychiatric diagnoses and
parent–child relational disturbances in a sample of
clinic-referred and comparison children.
Tools for comprehensive assessment
of social-emotional/behavioral problems
More comprehensive assessments are required for
clinical evaluations and for research studies that
focus on clinical populations or that aim to utilize
profiles of problems and competencies (see examples
in Table 4). Recently, there has been an increase in
the number of checklist measures available for

Table 3 Selected social emotional screening instruments
Brief Infant–Toddler Social
Emotional Assessment
(BITSEA) (Briggs-Gowan
& Carter, 2001)
Age range 12–36 months
Respondent Parent or caregiver
Number of items 42 items
Admin. Time 5–7 minutes
Skills/Domains assessed Problem behaviors
Competencies
How items are scored 3 point rating scale:
Not true/rarely
Somewhat true/
sometimes
Very true/often
Scoring/Cut-points Problem and competence
index totals as well as
cut-points based on
child age and sex.
Combined cut-point
(presence of problems
and/or low competence).
Language Available in Spanish,
and cultural validity French, Dutch, Hebrew.
Reading level 4th to 6th grade
Ages and Stages
Questionnaires–
Social-Emotional (ASQ-SE)
(Squires, Bricker, &
Twombly, 2002)
6–60 months
Parent or caregiver
19–33 items
10–15 minutes
Social-emotional problems
Behavioral problems
Social competencies
3 point rating scale:
Most of the time
Sometimes
Never or rarely;
Rating of whether
the behavior is concerning
to the respondent.
High score suggests
need for further evaluation.
Low score suggests the
respondent considers
social-emotional behaviors
to be competent.
Available in Spanish.
Authors suggest
excluding any items
that are not culturally
appropriate.
5th to 6th grade
124
Alice S. Carter, Margaret J. Briggs-Gowan, and Naomi Ornstein Davis
Toddler Behavior Screening Devereux Early EybergChild Behavior
Inventory (TBSI) Childhood Assessment Inventory (Colvin &
(Mouton-Simien, McCain, (DECA) (LeBuffe & Eyberg, 1999; Eyberg,
& Kelley, 1997) Naglieri, 2003) 1980)
12–42 months 2- to 5-year-olds 2 1/2 to 11 years
Parent or caregiver Parent or caregiver Parent
40 items 37 items 36 items
Not reported. 5–10 minutes 5 minutes
Problem behaviors Initiative Conduct problems
Self control Aggression
Attachment Inattention
3 point rating scale: 5 point rating scale: Items are rated
Not true Never for intensity on a 7-point
Somewhat/sometimes true Rarely frequency scale from
Very/often true Occasionally Never to Always.
Rating of whether the Frequently Parents also rate whether
respondent considers the Very frequently each item is a
behavior to be a problem. problem (yes or no).
Cut-points are offered. Three ranges for Cut-points are offered
Authors suggest Protective factors, reflecting need for
follow-up with family reflecting concern, referral or no need
on any behavior typical or strength. for referral.
that is reported to be For Behavioral Concerns
problematic. cut-points indicate
concern and no concern.
Scales were examined Available in Spanish. Examination of
for SES and ethnicity Scales were examined Caucasian and African
effects (McCain et al., 1999). for racial bias with American families
small effect sizes indicated no effects of
reported. race on the scales
(Colvin & Eyberg, 1999).
Not reported 6th grade Not reported.
 Infant–toddler assessment 125

Table 4 Selected social-emotional assessment instruments

Infant-Toddler Social Child Behavior Checklist Preschool Age Psychiatric

and Emotional Assessment (ITSEA) ages 1.5–5 (CBCL) (Achenbach Assessment (PAPA) (Egger,
(Carter & Briggs-Gowan, 2000) & Rescorla, 2000) Ascher, & Angold, 1999)

Age range 12–36 months 18–60 months 2–5 years

Format Questionnaire Checklist/questionnaire Structured interview
(can be administered
as an interview)
Respondent Parent or caregiver Parent or caregiver Parent or caregiver
Number of items 139 in scales 99 items 15 diagnostic modules
27 in indices
Administration time Approximately 30 minutes 15 to 20 minutes 1½–2hours
Skills/Domains Externalizing Externalizing Modified DSM-IV and ICD-10 criteria
assessed Internalizing Internalizing DC:0–3 symptoms and diagnoses;
Dysregulation Total Problem Brief developmental assessment;
Competencies DSM Oriented scales Family structure and functioning;
Maladaptive behavior Incapacities
Atypical behavior
Social relatedness
Scoring of items 3-point rating scale: 3-point rating scale: Yields diagnosis
not truly/rarely not true and incapacity scores
somewhat true/sometimes somewhat/sometimes true
very true/often very true/often true
No opportunity
Scoring of problem Cut-points are available Cut-points are available. Scoring is accomplished through
areas by child age and sex computerized algorithms.
Language and Use with low SES Available in Spanish Spanish language translation
cultural validity Available in Spanish, French, is currently under way
Dutch, Hebrew
Level of difficulty 4th to 6th grade reading level. 5th grade reading level Lay interviewer trained to reliability
to complete Can be administered orally
if family prefers
Level of training Interpretation requires Interpretation requires 1–2 weeks classroom training;
to administer knowledge of standardized knowledge of standardized Individuals from a range
assessment and supervised assessment and supervised of professions can be trained
training in working with training in working with the to administer.
the relevant kinds of clients. relevant kinds of clients.

assessing social-emotional/behavioral adjustment and Competence), as well as three indices (Social

in young children. The Infant-Toddler Social and
Emotional Assessment (ITSEA) (Carter & Briggs-
Gowan, 2000; Carter et al., 2003), developed for 1-
to 3-year-olds, and the downward extension of the
Child Behavior Checklist, now available for 18-
months to 5 years of age (CBCL/1.5-5, Achenbach &
Rescorla, 2000), reflect this growth in checklist
measures. One of the advantages of longer dimen-
sional assessments, as compared to screening tools,
is that profiles of problems and competencies can be
examined for areas of relative strength and concern
or for identifying clusters of children who vary across
score profiles.
Infant-Toddler Social and Emotional Assessment
(ITSEA). The ITSEA (Briggs-Gowan & Carter, 1998;
Carter & Briggs-Gowan, 2000; Carter et al., 2003) is
a 169-item questionnaire about social-emotional/
behavioral problems and competencies in 1- to 3-
year-old children. The ITSEA was developed as a
comprehensive tool that would be appropriate for
profiling children’s strengths and weaknesses in the
social-emotional domain. There are four broad do-
mains (Internalizing, Externalizing, Dysregulation,
Relatedness, Atypical Behaviors, and Maladaptive)
that consist of low base rate, clinically significant
behaviors. Reliability and validity have been evalu-
ated in three studies (Briggs-Gowan & Carter, 1998;
Carter, Little, Briggs-Gowan, & Kogan, 1999; Carter
et al., 2003). Of note, early work with the ITSEA
documented validity relative to independent obser-
vational ratings of child behavior in a sample of
toddlers (Carter et al., 1999). Most recently, the
psychometrics of the ITSEA were examined in a large
representative healthy birth cohort of urban and
suburban families (Carter et al., 2003). Results
indicated acceptable internal consistency and test–
retest reliability. In addition, criterion-related valid-
ity was supported by moderate correlations between
ITSEA problem scales and parent reports on the
CBCL/1.5–5, as well as by small to modest correla-
tions with independent evaluator’s ratings of prob-
lem behaviors. Further, consistent with the
developmental nature of ITSEA Competence, chil-
dren’s scores in this domain increased with child
age. ITSEA Competence was also positively and
moderately associated with the results of standard-
ized developmental tests (r ¼ .39 to .58). Scale scores
126 Alice S. Carter, Margaret J. Briggs-Gowan, and Naomi Ornstein Davis
and cut-point status, reflecting the extreme 10th
percentile, are derived from the subscales and
domains of ITSEA. In addition, t-scores have been
developed at the domain level.
Child Behavior Checklist for 1.5-5 (CBCL/1.5-5)
(Achenbach & Rescorla, 2000). This 99-item
checklist measure is a downward extension of the
CBCL, originally developed for older children, and is
designed for children from 18 months through
5 years. The CBCL/1.5-5 addresses social-emo-
tional/behavioral problems in three domains (Inter-
nalizing, Externalizing and Total Problems) and
includes new DSM-Oriented scales, designed to
parallel symptoms in DSM diagnostic areas. Indi-
vidual social-emotional competencies are not rated in
the CBCL/1.5-5. Scoring yields both t-scores and
cut-point status scores. The cut-points fall in two
ranges: ‘Sub-clinical’ (t-score ‡60) and ‘clinical’
(t-scores ‡63). The CBCL/1.5-5 has demonstrated
very good 8-day test–retest reliability and cross-
informant agreement. There is evidence that the
CBCL/1.5-5 discriminates children referred to men-
tal health and special education facilities from
matched subjects from a normative sample, with 74%
of referred children correctly classified by the Inter-
nalizing and Externalizing scales. Furthermore,
results reported by Achenbach and Rescorla (2000)
indicate that children with high CBCL/1.5-5 domain
scores were 5 to 6 times more likely to be clinically
referred than children with scores below the cut-
points.
Diagnosis in early childhood
Recent advances in screening and assessments of
social-emotional and behavior problems and com-
petencies have been paralleled by major progress in
conceptualizing the early emergence of psychopa-
thology with respect to psychiatric diagnosis. This
progress is reflected in empirical work by several
groups of clinical researchers that addresses specific
aspects of psychopathology such as Post Traumatic
Stress Disorder (PTSD), Depression, Disruptive
Behavior Disorders, and Attachment Disorders. In
addition, progress is evident in the revisions of exist-
ing measures (e.g., K-SADS and C-DISC) for use with
younger children and the design of new measures.
Diagnostic assessment measures. The Preschool
Age Psychiatric Assessment (PAPA; Egger, Ascher, &
Angold, 1999) was recently developed to provide
comprehensive and developmentally sensitive cov-
erage of the symptom, frequency, duration and onset
criteria necessary to generate diagnoses for children
ages 2 to 5 using the DSM-IV, ICD-10, and DC: 0–3
diagnostic classification systems. Reviews of the in-
fant mental health literature and input from many
infant mental health experts were used to design
sections on internalizing disorders, externalizing
disorders, regulatory disorders (addressing, for
example, sleep, feeding, and emotion regulation),
Post-Traumatic Stress Disorder, and Reactive
Attachment Disorder (Egger & Angold, in press). The
PAPA interview also includes a section for de-
termining the level of impairment, or ‘incapacity,’
that is associated with symptoms of each diagnostic
area. Preliminary findings from a recent study indi-
cate that the PAPA achieves test–retest reliability
comparable to that of other diagnostic tools of older
children (Egger, 2003).
Advances in conceptualization of disorder in early
childhood. Building on the emerging body of
empirical diagnostic work with young children, an
interdisciplinary task force of independent invest-
igators gathered recently to make recommendations
regarding clearly specified diagnostic criteria that
can be used in systematic research on psychiatric
disorders in infants and preschool children (Task
Force on Research Diagnostic Criteria: Infancy and
Preschool, in press). This group developed the Re-
search Diagnostic Criteria – Preschool Age (RDC-PA)
in a process analogous to that which led to the
development of research diagnostic criteria for use in
general psychiatry (Spitzer, Endicott, & Robins,
1978). After considerable discussion of the status of
the extant diagnostic nosologies (i.e., DSM-IV, DC:
Zero to Three, ICD-10), a focus was placed on gen-
erating testable and developmentally sensitive cri-
teria consistent with the DSM-IV approach to
conceptualizing psychopathology. The work was in-
formed by a review of over 40 empirical articles that
focused on psychopathology in children younger
than 5 years of age.
The guidelines for developing the criteria were as
follows: (1) Wherever possible, adhere to the DSM-
IV; (2) Modifications to criteria should be based on
empirical evidence; (3) Criteria that require infer-
ence of internal states should not be included (e.g.,
if a pre-verbal child wakes up crying in the night, it
is not legitimate to assume the child is awakening
from a nightmare); (4) Maintain a focus on the
child’s symptomatology, such that parental behav-
iors are not included as criteria for child disorders;
and (5) Maintain a clear distinction between symp-
toms and disability or impairment. For some dis-
orders, such as disruptive behavior disorders, the
group concluded that minimal changes in dia-
gnostic criteria were necessary for young children.
In contrast, for PTSD, many revisions to wording
were required to make symptoms developmentally
appropriate. Moreover, many symptoms that are
applicable for older children and adults are not
relevant for very young children. When clinical- or
research-based evidence indicated that the existing
nosological criteria did not adequately capture the
phenomenology of a particular disorder in young
children or were developmentally inadequate (e.g.,
as in Reactive Attachment Disorder), new criteria

were created or existing criteria modified to be
developmentally-sensitive.
Several disorders were minimally modified (e.g.,
Attention-Deficit/Hyperactivity Disorder, Opposi-
tional Defiant Disorder), others were moderately
modified (e.g., Conduct Disorder, Posttraumatic
Stress Disorder), while others required conceptual
alterations (e.g., Reactive Attachment Disorder,
Sleep Onset Protodyssomnia, several feeding disor-
ders). Of the 87 symptoms that were reviewed across
13 DSM-IV disorders, 51% were not altered, 34%
were developmentally modified, and 15% were con-
sidered developmentally inappropriate. Twenty-two
new symptom categories were created and 10
experimental symptoms were offered for further
study. The RDC-PA are available on-line at http://
www.infant.institute.org.
Although a review of each area addressed by the
RDC-PA is beyond the scope of this paper, a brief
review of some of the recent work conducted by
Schereenga and Zeanah (1994, in press) in PTSD,
Luby and colleagues (Luby, Heffelfinger, & Mra-
kotsky, 2002; Luby et al., 2003) in Depression, and
Keenan and Wakschlag (2000, 2002; Wakschlag &
Danis, in press) in Disruptive Disorders is included
to highlight the importance of the conceptual and
methodological strategies employed to validate dis-
orders in very young children.
Posttruamatic Stress Disorder (PTSD). The work of
Michael Schereenga and colleagues (Scheeringa, in
press; Scheeringa & Gaensbauer, 2000; Scheeringa,
Peebles, Cook, & Zeanah, 2001; Scheeringa, Zeanah,
Drell, & Larrieu, 1995) documents that infants older
than 9 months of age and toddlers can and do suffer
from PTSD. It also highlights the importance of
understanding the child’s developmental capacities
when determining the appropriateness of criteria
employed for older children and illuminates the
utility of adopting a multi-informant, multi-method
approach to assessment. Moreover, by systematic-
ally evaluating young children exposed to significant
stress and reviewing the basic research on memory
processing in infancy and toddlerhood, Schereenga
and colleagues have made a very strong case that
many of the DSM-IV criteria for PTSD are not
applicable to very young children due to their more
limited cognitive, verbal, and memory capacities.
They also suggest that young children evidence un-
ique behaviors that may need to be incorporated into
modified diagnostic criteria. They further have
documented the central role that parental reactions
play in the emergence, promotion, and/or mainten-
ance of symptoms in young children and propose a
variety of mechanisms that can account for these
associations (Scheeringa & Zeanah, in press).
Depression. Luby and colleagues have been ex-
amining the early manifestations of clinically sig-
nificant signs and symptoms of depressive
Infant–toddler assessment 127
disorders (Luby et al., 2002, 2003). Their work
addresses the complicated developmental question
of whether the young child’s emotional repertoire is
itself sufficiently differentiated to encompass true
‘depressive’ and/or ‘elated’ affect and how to dif-
ferentiate atypical from normative developmental
manifestations. Clinicians and researchers are lim-
ited by the fact that the current DSM nosology does
not describe the developmentally specific manifes-
tations of affective symptoms for young children.
Their work indicates that given the greater variab-
ility in mood states observed in young children, it is
not clear that the duration criteria should be com-
parable to older manifestations (Luby, in press).
Luby and colleagues utilized a multi-method, multi-
informant approach that included: (1) an age
appropriate diagnostic interview; (2) observation of
the young child’s affective range using a laboratory-
based temperament assessment; (3) a developmen-
tally appropriate direct interview for preschoolers;
(4) an examination of thematic play; (5) parental
dimensional ratings scales; (6) an observation of the
parent–child interaction across structured and
unstructured conditions; and (7) cognitive and
neurocognitive assessment of the child. By
employing these techniques, they were able to
identify a group of young preschool children who
met the modified depression criteria developed for
young children.
It is important to note that Luby and colleagues’
empirical data indicate that young children with
Major Depressive Disorder (MDD) are less withdrawn
and have less consistent vegetative symptoms than
do older children (Luby, in press). However, the
children were consistently described as ‘less happy’
and showed less pleasure in play activities, consis-
tent with an anhedonic depressive presentation. In
addition, changes in activity, appetite and sleep were
noted. Anhedonia appears to be a very specific
marker of depression in young children, with 57% of
children with depression evidencing this symptom,
in contrast to none of the children in the psychiatric
or typically developing control groups (Luby et al.,
2002). Moreover, Luby et al.’s (2003) work is notable
for addressing the relation of biological correlates,
such as cortisol reactivity, and family genetic risk to
disorder status among preschoolers.
Disruptive Behavior Disorders (DBD). The study of
disruptive behavior disorders highlights the com-
plexity of distinguishing normative from clinically
problematic behavior during early childhood when
some disruptive behaviors are increasing in a nor-
mative frame. Indeed, some have questioned
whether disruptive behavior problems can be reli-
ably assessed during this period (Campbell, 1990)
and whether it may be premature to diagnose a child
whose developmental trajectory may include dimi-
nution of symptoms without intervention. At the
same time, disruptive behavior is the most common
128 Alice S. Carter, Margaret J. Briggs-Gowan, and Naomi Ornstein Davis
reason for referral of young children to mental health
clinics (Keenan & Wakschlag, 2000; Luby & Mogan,
1997; Thomas & Guskin, 2001) and there is in-
creasing evidence from research endeavors that be-
havior disorders can be validly diagnosed in
preschoolers (Keenan & Wakschlag, 2002). Although
still in a very early stage of development, Wakschlag
and colleagues (Wakschlag & Danis, in press) have
an exciting new observational measure of Disruptive
Behavior Disorders, the Disruptive Behavior Dia-
gnostic Observational Schedule (DB-DOS), which is
modeled on the Autism Diagnostic Observational
Schedule (Lord et al., 2000). The DB-DOS presents
multiple opportunities to elicit behaviors relevant to
diagnosing disruptive behavior disorders. The DB-
DOS includes structured observations of the child
with the parent and with an examiner who is either
involved with the child or disengaged (Wakschlag &
Danis, in press).
As our understanding of specific early-emerging
disorders evolves, it is quite likely that additional
diagnosis-specific instruments will be developed al-
lowing clinicians and researchers to elicit targeted
information about behaviors that assist in making
differential diagnoses (i.e., are specific to diagnostic
conditions). Clearly, multi-method, multi-informant
assessment is integral to understanding young
children’s development. Moreover, observations of
the parent–child or caregiver–child interactions
across several contexts must be considered a critical
component of any young child assessment of social-
emotional problems or psychopathology. It has also
been argued that for very young children, repeated
assessments on more than one day are necessary to
capture the child and family’s range of functioning
adequately (Weston et al., 2003).
Summary and conclusions
In this paper we have tried to document some of the
recent advances in the conceptualization and
assessment of early-emerging social-emotional and
behavior problems, competencies, and psychopa-
thology. Considerable evidence documents that
young children evidence significant psychopathol-
ogy (cf., Del Carmen & Carter, in press; Emde,
1999; Zeanah, 2001; Zeanah et al., 1997). Given
the range of new assessment measures that have
become available over the past 10 years, the field of
young child mental health is poised for dramatic
gains in knowledge. It is critical to conduct large-
scale, longitudinal, epidemiological studies to in-
form our understanding of the course of psycho-
pathological conditions within the context of a
normative developmental framework. Multi-method,
multi-informant assessment approaches are more
essential in early childhood due to young children’s
inability to provide self-reports and the embedded
nature of children’s development in their caregiving
contexts. Screening large representative samples
affords the opportunity to ascertain unbiased clin-
ically informative sub-samples for methodologically
intensive sub-studies. These sub-studies can ad-
dress the child’s cognitive and linguistic develop-
mental capacities as well as utilize observational
methods to examine the relational context. This
approach provides an opportunity to merge dimen-
sional and diagnostic assessments and will yield
critical information for disentangling continuities
and discontinuities in normative and atypical
development.
The assessment methodology currently exists to
routinely screen very young children for social-emo-
tional and behavior problems as well as delays in the
acquisition of competencies in pediatric settings as
well as in early intervention programs. Yet, despite
the likely long-term benefits and cost-saving poten-
tial of early identification and intervention services,
short-term cost and knowledge barriers currently
limit widespread implementation. Discussions with
pediatricians suggest that one of the greatest barriers
to screening is the limited availability of mental
health referral sources. Indeed, very few children who
are rated by parents as having elevated social-emo-
tional and behavior problems are receiving any be-
havioral health services (Horwitz et al., in press).
Unmet mental health needs exist among non-referred
children in the community as well as among children
receiving early intervention services for developmen-
tal concerns. Documenting the mental health needs
of young children may promote training of profes-
sionals who have the competence to treat young
children and their families. Moreover, the availability
of social-emotional and behavior problem assess-
ment tools should increase studies that focus on the
clinical efficacy and effectiveness of prevention and
early intervention programs designed to promote
positive mental health.
Finally, although significant progress is occurring
in the arena of young child diagnosis, a strong case
can be made for intervening when young children are
exhibiting elevations in problem behaviors or delays
in the acquisition of competence. This is particularly
true when children are also experiencing exposure to
multiple contextual risk factors. It is therefore
important to advocate for changes to systems that
require child diagnosis as a gateway to intervention.
As we learn more about the precursors or prodromal
manifestations of clinical psychopathology we will be
able to examine the efficacy of earlier targeted pre-
ventive intervention approaches.
Correspondence to
Alice S. Carter, Department of Psychology,
University of Massachusetts Boston, 100 Morrissey
Boulevard, Boston, MA 02125, USA; Email: alice.
carter@umb.edu

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