J Child Fam Stud (2015) 24:225–236
DOI 10.1007/s10826-013-9828-9
ORIGINAL PAPER
Emotional and Behavioural Difficulties in Preschool
Maria S. Poulou
Published online: 20 September 2013
Ó Springer Science+Business Media New York 2013
Abstract The rapid developmental changes occurring
during early childhood place children at risk of emotional
and or behavioural difficulties (EBD). While some pre-
school children sooner or later overcome the transient
developmental difficulties, there is a large number of
children for whom these difficulties are predictive of future
developmental maladjustment. The preschool period is
deemed as the optimal time to identify and reduce early
signs of problems, before they develop into permanent
patterns. Studies suggest that children’s preschools repre-
sent a key component in building a comprehensive system
of prevention and early intervention. Yet, the picture of
emotional and behavioural difficulties in early childhood is
rather fragmented and clinically oriented. This paper aims
to present recent empirical evidence over the nature and
different aspects of emotional and behavioural difficulties
of preschool children (children ages 3–6 years old), and
address the need to consider EBD from an educationally
oriented perspective. Recent findings concerning the defi-
nition, taxonomy, prevalence, stability, comorbidity, gen-
der and age differences, aetiological factors, identification,
assessment, prevention and early intervention of emotional
and behavioural difficulties are reviewed. This review will
aid researchers, educators and other health professionals
working in the area of EBD.
Keywords Emotional and behavioural difficulties

Early childhood education
Identification

Assessment
Prevention
M. S. Poulou (&)
Department of Educational Science and Early Childhood
Education, University of Patras, Patras, Greece
e-mail: mariapoulou@yahoo.com; mpoulou@upatras.gr
Introduction
Emotional and behavioural difficulties displayed by young
children represent a growing concern for early childhood
professionals. Until now, there has been a reliance on
viewing childhood problems as ‘‘downward extensions’’ of
adult or adolescent problems (Wakschlag et al. 2010).
Nowadays, mental health problems affect up to 20 % of
children in modern western societies, including preschool-
aged children (Bayer et al. 2008). Mental health problems
mainly consist of emotional disorders (such as anxiety,
fears, phobia and depression), behavioural disorders
(ADHD and the disruptive behaviour disorders, Opposi-
tional Defiant Disorder (ODD) and Conduct Disorder (CD),
autistic spectrum disorders, psychotic disorders, eating
disorders and substance and drug abuse. The literature to be
reviewed will focus on emotional and behavioural prob-
lems, commonly met in mainstream schools. Research on
autistic, psychotic or eating disorders and substance abuse
will not be considered. Rather, emphasis will be given to
emotional and behavioural difficulties that are present in
preschool years, and may either disappear with develop-
ment, or continue as difficulties or disorders in middle
childhood.
This paper explores the available research evidence
concerning emotional and behavioural difficulties and
disorders in preschool years (up to 6 years old). It covers
disruptive behaviour problems with symptoms of opposi-
tional and attentional disorders and emotional problems
such as phobias, anxiety and depression. Focusing pri-
marily on young children, studies referring to preschool
(3–6 years) will be reviewed. This review is meant to
represent current studies in the area, rather than an
exhaustive review of all relevant studies. Therefore, find-
ings from more recent studies will be emphasized. The
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226
information reviewed is rather fragmented in the literature
and derived mainly from clinical and epidemiological
studies. Current paper aims to present a rather compre-
hensive picture of EBD phenomenon in preschool years.
The information reviewed further advocates the need to
address EBD phenomenon from an educationally and
pedagogically relevant scope, and work towards evidence-
based treatments in school settings. The paper begins by
considering common developmental aspects, prevalence,
stability and comorbidity of early behaviour problems,
followed by causal explanations, identification criteria,
assessment and treatment of emotional and behavioural
problems. Finally, based on the developmental-ecological
framework (Sameroff and Fiese 2000) which recognizes
the development of emotional and behavioural problems as
a function of the dynamic transaction between situational
demands and child capacities over time, the paper also
reviews educationally relevant studies. Perceptions of
preschool educators, educationally relevant assessment and
evidence-based treatment, as well as future research efforts
are further discussed. Utilizing the reviewed procedures to
clarify the quite vague picture of EBD, can have a sub-
stantial impact in research and practice settings, in
developing, testing and implementing preventive and early
intervention programmes for preschoolers.
Method
The aim of the present review is to make a synthesis of the
information available concerning certain aspects of emo-
tional and behavioural difficulties in preschool children
(3–6 years old), and address the question: what are the
current trends in literature about the phenomenon of EBD
in preschool, through the lenses of psychopathology,
psychology and education? Several searches in PsychInfo,
ERIC, First Search, Scopus and Wilson Web were con-
ducted. One key search term string was (emotional * or
behavioural * or internalizing* or externalizing*) AND
(difficulties* or problems* or disorders*) AND (preschool
children* or kindergarten children* or early school chil-
dren* or young children*) AND (review of the literature*)
AND (causes*) AND (assessment*) AND (prevention* or
intervention*). The studies retrieved sampled clinical or
community population derived from kindergartens or day-
care centers, in an age range from 3 to 6 years. For the
purpose of this review, we focused on studies published
during the last two decades, in peer review journals,
mainly conducted in community population in western
contexts, and referred to preschool children with emo-
tional and behavioural difficulties or disorders up to
6 years old.
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General Findings
Definition of Emotional and Behavioural Difficulties
Social, Emotional and Behavioural Difficulties (SEBD), a
term mainly employed in U.K studies, has been defined as
‘‘behaviours or emotions that deviate so much from the
norm that they interfere with the child’s own growth and
development and/or the lives of others’’ (Cooper 2011,
p. 71–72). Conceptually similar definition is given to
emotional and behavioural responses in U.S studies,
employing however the term of Emotional and Behavioural
Disorders. Emotional and behavioural disorders are defined
as:
a condition in which a child’s behavioral or emo-
tional responses are so different from those of the
generally accepted age-appropriate norms of children
with the same ethnic or cultural background as to
result in significant impairment in social relation-
ships, self-care, educational progress or classroom
behaviour (Head Start Performance Standards, in
Fantuzzo et al. 2001, p. 142).
Irrespective of the terms employed, these definitions
reflect the need to distinguish disorders from age-appro-
priate behaviours, transient conflicts and symptoms.
According to Campbell (1995) a definition of disorder in
young children should include: (1) the presence of a pattern
or constellation of symptoms; (2) a pattern of symptoms
with at least short-term stability that goes beyond a tran-
sient adjustment to stress or change, (3) a cluster of
symptoms that is evident in several settings and with
people other than the parents (4) a cluster of symptoms that
is relatively severe and (5) the presence of symptoms
which interfere with the child’ ability to negotiate devel-
opmental challenges, thereby reflecting some impairment
in functioning (Campbell 1995, p. 117).
Behavioural problems are typically divided into two
general categories: externalizing and internalizing prob-
lems. Externalizing problems are outer-directed and
involve acting out, defiant and noncompliant behaviours.
Internalizing problems are more inner-directed and involve
withdrawal, depression and anxiety. Moreover, the inter-
nalizing-externalizing distinction met in the literature to
taxinomize these disorders, represents the most consis-
tently empirically identified classification of psychopa-
thology across ages, including the early preschool years. It
is considered useful in the identification of early child and
family risks factors (Cicchetti and Toth 1991).
Current study refers to emotional and behavioural diffi-
culties, or problems, or disorders (the term ‘‘disorder’’ is
used in this age group with some skepticism on its validity),
J Child Fam Stud (2015) 24:225–236
depending on the severity of emotional and behavioural
symptoms, and uses interchangeably the terms emotional or
internalizing and behavioural or externalizing behaviours,
as they are reflected in the literature.
Taxonomy of Emotional and Behavioural Difficulties
Although the current literature is extensive, it is also rather
fragmented with studies mainly focusing to externalizing
problems. In turn, studies on externalizing behaviour focus
on ADHD and disruptive behaviour, with aggression by far
the most studied dimension of disruptive behaviour. Dis-
ruptive behaviours such as high levels of noncompliance
and aggression are identifiable as early as the preschool
years. High levels of noncompliance and aggression in
early childhood are risk markers, but not all disruptive
preschoolers develop disorders (Cole et al. 1996). Longi-
tudinal research indicates that early disruptiveness is pre-
dictive of later behaviour disorders. In order to understand
the origins of aggressive behaviour, specifically, we need
to focus on the development of aggressive behaviour dur-
ing the first few years after birth, and differentiate among
forms of aggressive behaviour (Tremblay 2000).
In contrast to the increasing consensus that disruptive
disorders are identifiable in preschool children (Wakschlag
et al. 2010), internalizing problems are less commonly
identified in young children. Reasons for this, might be
children’s inability to easily communicate about their
emotions, or adults’ inability to notice emotional difficul-
ties as worrying, or even difficulty in distinguishing
developmentally normal emotions from prolonged distress
that constitutes a disorder (Gardner and Shaw 2008).
Nevertheless, internalizing as well as externalizing prob-
lems share the same axiom: increase of problems across the
childhood years is predictive of continued adjustment
problems in later childhood (Kerr et al. 2007).
Early Onset and Prevalence of Emotional
and Behavioural Difficulties
Children with a prior diagnosis are likely to continue to
exhibit problems and deserve particular attention. Although
there is a reduction in certain kind of problems around
5 years, a wide range of disorders have their onset in the
preschool years. Even so, little attention has been paid to
the earliest onset of these problems in the preschool years.
Only temperament is most closely related to early-onset
behaviour problems, while other family and maternal per-
sonality characteristics show stronger associations with
long-term prognosis, or with problems of later onset (Bayer
et al. 2011; Hughes and Esnor 2007; Lavigne et al. 1996;
Rubin et al. 2003). Thus, internalizing and externalizing
behaviour were higher in children with easy temperament,
227
whereas an easy temperament acts as a protective factor for
social and emotional development (Derauf et al. 2011).
Even though it is well documented that early problems
occurring in multiple settings and relationship systems are
generally more serious and stable (Kerr et al. 2007), further
research is needed to examine the risk factors and patterns
of change in a wide range of disorders that have their onset
or maintenance in the preschool years. As Egger and An-
gold (2006) state ‘‘in order to truly understand the ‘early
onset’ of disorders, we can start no later than the preschool
period’’ (p. 314).
The compelling need to explore emotional and behav-
ioural difficulties in preschool years is further highlighted
by literature base assertions that the prevalence of emo-
tional/behavioural problems in young children is increasing
(Brauner and Stephens 2006; Lutz et al. 2002). It is also
recognized that preschool children experience emotional
and behavioural difficulties with similar prevalence as
older children (Egger and Angold 2006; Fantuzzo et al.
2001). Epidemiological studies for preschool children
report prevalence of behaviour problems in the 15–20 %
range (Gothelf et al. 2006; Hulle et al. 2007; Pianta and
Caldwell 1990). Lavigne et al. (1996) found that about
20 % of preschool children suffer from early emotional or
behaviour disorders with oppositional defiant disorder as
the most common, reported for 16.8 % of children. In their
study for preschoolers internalizing and externalizing
problems received similar ratings: The prevalence of pure
internalizing and pure externalizing problems was 3.7 %
each. Similar prevalence rates for internalizing and exter-
nalizing diagnosis was found elsewhere (Mesman and Koot
2001). A possible explanation for this similarity given from
Lavigne et al. (1996), was the occurrence of developmental
changes in the organization of such symptoms; that is
internalizing symptoms are present, but not clearly orga-
nized into patterns recognizable at this age. The opposite is
true for the externalizing symptoms which are already
organized into more recognizable patterns in some instan-
ces. Further support to this argument comes from Coplan
et al. (1994) study of solitude, in which they established the
presence of multiple and independent forms of solitude in
preschool-age children, and made it clear that social
withdrawal has many overlapping ‘‘meanings’’. Loneliness
was also found to be a marker variable for both early
internalizing and externalizing problems. The direct asso-
ciations found between loneliness/dissatisfaction and both
overt aggression and shyness/withdrawal (Cassidy et al.
2003), peer exclusion, poorer friendship quality, school
avoidance, peer victimization, and lower perceived com-
petence (Coplan et al. 2007) add further evidence that
internalizing problems present a vague picture. Evidence
for different prevalence rates was also found with higher
rates met either to externalizing problems (Pianta and
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Table 1 Studies on prevalence

References Population Range of ages Instruments Source of data
of emotional and behavioural
difficulties, in preschool age Gothelf et al. Clinical 3–6.5 years Clinical data (biological
(2006) (Israel) parameters,
developmental
milestones, intelligence
level, socioeconomic
status, stressful life
events)
Hulle et al. Community 17–4.8 months Infant-Toodler Social and Parents
(2007) (USA) Emotional Assessment
(I.T.S.E.A)
Pianta and Community 5 years Standford-Binet (4th ed; Parents, teachers
Caldwell (USA) SBFE); family
(1990) demographics; semi-
structured problem
solving tasks on
mother–child
interactions; Preschool
Behavior Rating Scale
(PBRS); Teacher–Child
Rating Scale (TCRS);
Cognitive Abilities Test
(CAT)
Lavigne et al. Community 2–5 years CBCL; Rochester Parents
(1996) (USA) adaptive behavior
inventory; play
observation
Mesman and Community 2–3 years Child behavior checklist Parents
Koot (2001) (Netherlands) for ages 2–3 years;
CBCL/2–3
Wichstrom Community 4 years SDQ; preschool age Parents
et al. (2011) (Norway) psychiatric assessment
(PAPA)
Dobbs and Community 3.4–5.3 years Teacher report form of the Preschool teachers
Arnold (USA) child behavior checklist;
(2009) classroom observations
Kontopoulou Community 2.6–6 years Interviews Preschool teachers
(2003) (Greece)

Caldwell 1990), or depressive disorders (Wichstrom et al.
2011).
The limited studies of preschoolers’ behaviour problems
according to teachers’ ratings clearly show the predomi-
nance of externalizing problems in relation to the inter-
nalizing ones. An average of 20 % of children had
moderate externalizing problems in kindergarten and first
grade (Dobbs and Arnold 2009; Pianta and Caldwell 1990).
In contrast, in a study of nursery school teachers’ percep-
tions of adjustment difficulties, emotional difficulties and
particularly isolation, was reported for 56 % of children
(Kontopoulou 2003) (Table 1).
Stability and Continuity of Emotional and Behavioural
Difficulties
The stability of problem behaviours as well as the stability
of preschool problem behaviours from the first years of life
has been recognized (Hughes and Esnor 2007). Having an
emotional or disruptive disorder consist of a strong risk
factor for later diagnosis (Lavigne et al. 1998). For exter-
nalizing problems particularly, within the preschool and
early school-age developmental period, they appear stable
and they predict other forms of psychopathology in later
years, unless protective factors are present. Studies provide
less support for continuity in internalizing symptoms over
time (Meagher et al. 2009). In fact, research on the stability
of early internalizing problems has presented mixed results.
There is evidence that internalizing problems are discon-
tinuous over time (Mesman and Koot 2000). On the con-
trary, there are studies supporting that early internalizing
problems predict later internalizing problems (Meagher
et al. 2009). That is early occurrence of anxious and
depressive symptoms are associated with later anxious and
depressive symptoms (Karevold et al. 2009; Nordahl et al.
2007).

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Furthermore, it is argued that externalizing behaviours
are more stable than internalizing behaviours at young ages
(Meagher et al. 2009; Pianta and Caldwell 1990). Studies
indicate a high stability of externalizing disorders (Rubin
et al. 2003), while children with early-onset conduct
problems have the poorest prognosis (Koglin and Peterman
2011). Hulle et al. (2007) provided evidence that the
behaviour problems exhibited between 12 and 24 months,
particularly disruptive disorders, predicted later internal-
izing and externalizing disorders at ages 3 and 5 years. In
their study, nearly half of infants and toodlers with high
social-emotional and behavioural problems continued to
have such problems approximately 1 year later. Pre-
schoolers with internalizing problems had almost threefold
increased risk for later similar problems, whereas children
with externalizing problems at age 2–3 years showed
almost 5 times higher risk for later similar problems
(Mesman and Koot 2001).
Besides the stability for both internalizing and exter-
nalizing problems in children from early years, there is a
substantial number of young children in the preschool and
early primary school years, approximately 20–30 %, who
even though showed no signs of disorder at preschool age,
they developed a diagnosable disorder over the next few
years (Lavigne et al. 1998). For case status in general
including disruptive and emotional disorders, children with
a diagnosis at age 2–5 years were two or 3 times more
likely than children with no diagnosis at that age, to con-
tinue to have a diagnosis in the early school years.
The transformation of one behavioural dimension into
another through childhood, further adds to the complexity
of behaviour problems under study and highlights the need
to focus on both early types of behaviour (Slemming et al.
2010). For instance, early externalizing difficulties could
be associated with future internalizing disorders (Meagher
et al. 2009; Mesman et al. 2001; Pihlakoski et al. 2006). In
addition, Slemming et al. found an association between
both preschool anxious and aggressive behaviour and later
emotional difficulties at age 10–12 years.
Comorbidity and Relations of Emotional
and Behavioural Difficulties with Other Problems
Although externalizing and internalizing problems are
relatively stable, there are shifts in patterns of comorbidity,
with patterns of comorbidity differing between emotional
and disruptive disorders (Lavigne et al. 1998). A number of
review articles have demonstrated the importance of
comorbidity for understanding the etiology, course and
treatment of externalizing and internalizing disorders. In
the studies reviewed, comorbidity of disorders was the
norm. Children with conduct or depressive disorders were
more likely to have another emotional or behavioural
229
disorder (Wichstrom et al. 2011). In Egger and Angold’s
(2006) study for instance, the risk of having comorbid
disorders increased 1–6 times with each additional year
from age 2 through age 5. Campbell et al. (2000) further
supported that problems are more likely to occur when a
young child presents a constellation of problems that are
frequent and severe, are met across different domains of
functioning, situations and people. Moreover, problems are
more likely to persist in family dysfunction context and
stress.
Besides comorbidity between behaviour problems, there
is a considerable relation between behaviour and learning
problems. Data indicate that the externalizing behaviour/
learning problems cluster is present even at entering school,
while the link between these problems grow stronger over
time (Pianta and Caldwell 1990). Behaviour problems have
been repeatedly found to predict low academic achieve-
ment, school dropout and the development of drug abuse in
adolescence, as well as other problems such as violence and
delinquency (Koglin and Peterman 2011). Raver et al.
(2009) expressed their concern that preschoolers’ behaviour
problems may significantly have an effect on preschoolers’
chances for later success in school. They found that young
children who are persistently sad, withdrawn or disruptive
receive less instruction from teachers, have fewer oppor-
tunities for learning from peers, and are less engaged and
positive about their roles as learners. Finally, young chil-
dren with behaviour problems are more likely to demon-
strate other concurrent difficulties, such as problematic peer
relations and insecure attachments (Bulotsky-Shearer et al.
2008; Hughes and Esnor 2007; Lutz et al. 2002), later
ADHD symptoms and social difficulties (Gewirtz et al.
2009).
Gender and Age Differences
In contrast to the hypothesis that gender differences prior to
age 4 are negligible, gender differences were found in ratings
of externalizing behaviour, with boys exhibiting higher
levels of aggressive, inattentive/hyperactivity behaviour
(Bulotsky-Shearer et al. 2008; Hulle et al. 2007; Lutz et al.
2002; Pianta and Caldwell 1990; Rubin et al. 2003; Wich-
strom et al. 2011), depression (Wichstrom et al. 2011) and
passivity problems (Fantuzzo et al. 2001) than girls. No
significant effects were found for conduct (Fantuzzo et al.
2001) or both externalizing and internalizing problems
(Mesman and Koot 2001). In advance, considerable stability
was found in externalizing behaviours for both boys and girls
(Pianta and Caldwell 1990). It was actually found that sta-
bility in the school years was higher for girls, with exter-
nalizing behaviour in kindergarten accounting for 10 %
more of the variance in grade 1 externalizing behaviour, than
for boys.
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While the overall rate of disorders are similar across the
life span, the pattern of specific disorders varies with age
(Egger and Angold 2006). For example, main effect was
found for age, with younger preschool children exhibiting
more withdrawal-low energy, socially reticent, inattentive
behaviour (Bulotsky-Shearer et al. 2008; Lutz et al. 2002)
and higher levels of passivity (Fantuzzo et al. 2001) than
older preschool children. In sum, research on both gender
and age differences is rather limited, while existing evi-
dence presents a rather vague picture.
Aetiological Risks of Emotional and Behavioural
Difficulties
Studies relating to the risk factors of emotional and
behavioural difficulties present contradictory results. Thus,
they argue that genetic factors influence both normative
and non-normative behaviour in young children, with
heritability accounting for greater than 50 % of the vari-
ance for internalizing and externalizing disorders (Hulle
et al. 2007). Some studies revealed that maternal stress and
harsh discipline parenting practices were consistent and
cumulative predictors of externalizing problems over the
first 3 years of life (Bayer et al. 2008; Brenner and Fox
1998). At the same time, key predictors of internalizing
problems appeared to be having no older siblings, small
family size, maternal stress, anxiety, harsh discipline
practices, parenting, and single parent or parental conflict
(Bayer et al. 2006, 2008; Pike et al. 2006). In other studies
though marital status, child’s gender, father’s absence,
crowdedness, family characteristics and maternal psycho-
pathology did not turn out to be correlates of disorders
(Lavigne et al. 1996; Thomas et al. 1991). Rather, demo-
graphic factors such as low SES, child’s gender, father
absence, family size and mainly child temperament and IQ
were correlates of behaviour problems (Hetherington 1989;
Lavigne et al. 1996). Biological risk factors, such as IQ,
perinatal complications and delayed milestones were found
to play a minor role, in comparison to low SES and high
stressful life events, which were found to have an over-
whelming negative impact on development (Gothelf et al.
2006; Wichstrom et al. 2011). For externalizing problems
particularly, only stressful life events remained a signifi-
cant predictor of later externalizing problems, after
accounting for parenting variables and child psychopa-
thology (Mesman and Koot 2001). Actually, preschool
emotional and behavioural difficulties are disproportion-
ately distributed among children from different familial,
socioeconomic and geographic backgrounds. Thus, young
children living in high-risk environments including pov-
erty, living in a single-female headed household and
exposure to multiple stressors associated with densely
populated urban settings, are most likely to manifest
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emotional and behavioural difficulties (Fantuzzo et al.
2001). Anselmi et al. (2008) on the other hand, challenge
the notion that cultural background and poor environmental
conditions might have an impact on different aspects of
mental health disorders. Their study in a developing
country provide evidence for the similarity in the conti-
nuity, stability and predictability of emotional and behav-
ioural problems with the developed countries.
After all, a large body of empirical literature consent
that exposure to multiple risk factors during critical periods
of development increases the likelihood that young chil-
dren will face emotional and behavioural difficulties in
school years as well. Developmental psychopathology
incorporates a transactional formulation (Sameroff and
Fiese 2000) that considers the interface between innate
child characteristics and environmental factors. Therefore,
maladaptive patterns of behaviour are the result of ongoing
exchanges within child and child-rearing context (Evan-
gelista and McLellan 2004). Campbell et al. (2000) sum-
marizes the risk factors emerged from studies, by arguing
that the small subgroup of boys with multiple risk factors
that include especially high levels of early hyperactivity
and aggression, and high levels of negative parenting and
family stress are most likely to exhibit continuing problems
at school entry.
In educational turns now, an enquiry of the most
developmentally challenging classroom situations for pre-
school children associated with more emotional and
behavioural problem behaviours revealed that three situa-
tional dimensions are related to preschool emotional and
behavioural problems: structured learning, peer interaction
and teacher interaction (Bulotsky-Shearer et al. 2008).
Teacher and peer social expectations, classroom rules,
attention to tasks, appropriate play, and the establishment
of friendships are some examples of preschool situational
dimensions. Specifically, situations requiring children to
exhibit more initiation and self-regulation in a group con-
text (free play, circle time instruction and completing
routine classroom ‘‘job’’ responsibilities) were associated
with more difficulties (Lutz et al. 2002). Disruptive chil-
dren experience significant interpersonal problems very
early in life, even before the transition to school. And these
problems are attributed more to failures in behavioural
regulation, than to problems in social understanding per se
(Hughes et al. 2000).
Identification and Assessment of Emotional
and Behavioural Difficulties
There is consensus in the literature that severe emotional
and behavioural difficulties occurring in the first 5 years of
life continue or deteriorate during the school-age years and
adolescence (Njoroge and Bernhart 2011). Early problem
J Child Fam Stud (2015) 24:225–236
behaviours account for about a third of the variance in later
problems (Hughes and Esnor 2007), while the risk of
worsening psychopathology in the preschool population
can both affect the self-esteem and self-efficacy of the
preschooler, and increase stressor on family relations
(Njoroge and Bernhart 2011). Therefore, acknowledging
that having an emotional or disruptive disorder is a strong
risk factor for later diagnosis, research effort has been
directed toward early identification of problem behaviours
in toodlers and preschool age children (Hulle et al. 2007).
In light of the growing evidence of onset of behaviour
problems as early as toodlerhood, early childhood repre-
sents a particularly important time to target children’s risk
of behaviour problems (Raver et al. 2009).
Beside the fact that research findings support the need
for early detection of emotional and behavioural difficulties
in preschool years, the difficulty in applying diagnostic
criteria to preschoolers still remains a challenge for early
identification efforts. Emotional and behavioural disorders
is a considerably heterogeneous group of symptoms, which
by definition generates diagnosis into a complex process.
Diagnosis in early childhood faces the challenge to dis-
tinguish symptoms of disorder from the normative misbe-
haviour of early childhood. High levels of behavioural
variation, rapid changes in behaviour, compliance demands
and expansion of the social world beyond the family that
occurs during this developmental period, add difficulties to
the identification task. This complexity though is not
unique to this age period. According to Pickles and Angold
(2003), the main point to the diagnostic approach is not
whether symptomatology in preschool children is measured
by dimensional (with problems lying in a certain cut point
of a continuum) or categorical (with problems meeting
specific criteria) means, but rather ‘‘under what circum-
stances’’. Wakschlag et al. (2010) further suggest that
variation during early childhood is not so extraordinary,
and measurement advances now provide methods for
assessing early childhood clinical patterns with the context
of this developmentally expectable variability.
In addition, the dearth of diagnostic studies regarding
disorders in preschoolers may be due to concerns whether
it is appropriate to apply diagnostic criteria to preschool
children (Egger and Angold 2006; Wichstrom et al. 2011).
Sterba et al. (2007) on the other hand, support that it is
reasonable to apply the DSM-IV nosology to preschoolers
as to older individuals. In fact their results not only indi-
cated that psychopathology in preschoolers is largely dif-
ferentiated according to DSM syndromes, but also showed
that the ways in which preschooler syndrome differentia-
tion departs from the DSM-IV nosology are strikingly
similar to those found in older children and adolescents.
Recent advances in the field include the Research Diag-
nostic Criteria-Preschool Age (RDC-PA) which attempted
231
to modify DSM criteria to be suitable for preschoolers
(Gardner and Shaw 2008).
Limited research in the early manifestation of behaviour
problems was among other things due to conceptual and
measurement gaps (Campbell et al. 2000). Multi-informant
(Kerr et al. 2007) and cross-contextual assessment of
children (Winsler and Wallace 2002) may contribute to a
better understanding of problem severity and future risk.
Valid self-reports by preschool children are usually not
available (O’Connor et al. 2011), and the identification of
problems relies solely on reports from parents and teachers
(Bagner et al. 2012). With preschoolers, understanding
diverging informant reports of children’s mental health
problems becomes pertinent (Berg-Nielsen et al. 2012).
This information can have far-reaching outcomes for the
early identification and referral of children with difficulties.
However, adult raters of children’s behaviour have
shown consistently low to moderate levels of agreement
(Winsler and Wallace 2002). This disagreement is mainly
located in internalizing problems (Meagher et al. 2009;
Berg-Nielsen et al. 2012). The common explanation for
this has so far been that children more likely confide in
their parents than their teachers about their emotional
problems. Teachers’ low ratings on internalizing problems
might also reflect that teacher might not be fully attuned to
early signs of internalizing symptoms (Meagher et al.
2009). It is the case that the more severe the child’s
problems are, the poorer the agreement between parents
and teachers (Berg-Nielsen et al. 2012). In general lines,
teachers report considerably fewer problems in children
than parents. What is noteworthy, is that teacher–child
conflict increases the discrepancy between teachers’ and
parents’ reports and when teachers compared to parents,
perceived high conflict with a child they report more
externalizing and internalizing problems (Berg-Nielsen
et al. 2012). Following these statements, it is not difficult to
realize the diagnostic uncertainty, when parents and
teachers disagree on three out of four children who have a
high problem severity.
Prevention and Early Intervention of Emotional
and Behavioural Difficulties
In the last decade, empirical research has challenged pre-
viously held beliefs that the incidence of serious emotional
and behavioural problems for preschool children is too low
to warrant extensive inquiry. Now, evidence suggests that
early intervention or preventive efforts is possible to reduce
the severity of externalizing and internalizing disorders and
even prevent their extension later in life (Harrington and
Clark 1998). And although most preschool children over-
come their symptoms, it is important to properly identify
the children who actually need early intervention. Essex
123
232
et al. (2009) argue that universal screening at school entry
can effectively identify children likely to develop recurrent
comorbid symptoms, and provides a basis for developing
optimal targeted intervention programs. Since only 20 % of
children in need of services receive specialty mental health
care in the USA, the authors conclude that we need to
develop cost-effective universal screening procedures to
identify early those children most likely to evidence per-
sistent impairing mental health problems. Studies in the
last decade suggest that targeting classroom processes can
be an effective way to reduce children’s behavioural
problems and that children’s preschools represent a key
component in building a comprehensive system of pre-
vention and early intervention (Bayer et al. 2008; Raver
et al. 2009).
Architects of early intervention programming are cur-
rently guided by the developmental–ecological theory,
which asserts the importance of supporting children’s
acquisition of age-appropriate competencies within rele-
vant social context (Coolahan et al. 2000). For preschool
children, relating successfully with classmates is a critical,
developmental task and a primary indicator of healthy
adjustment in kindergarten. The expression of autonomy
and ability to maintain prosocial interactions in play are
primary indicators of the psychological adjustment of
preschool children (Fantuzzo et al. 2001). On the other
hand, longitudinal research has linked poor peer relations
with detrimental consequences during later developmental
periods. Specifically, the display of aggression in peer
interactions is associated with externalizing behaviour
problems, and withdrawn from peer interactions is associ-
ated with internalizing behaviour problems (Coolahan et al.
2000). Since peer relationships in turn predict numerous
long term outcomes, intercepting these early negative tra-
jectories is an urgent not only clinical challenge (Hughes
and Esnor 2007), but educational challenge as well.
At this point, social and emotional skills training that
teach children social, emotional and cognitive competencies,
is useful, since deficits in these domains are empirically
proven risk factors for emotional and behavioural difficul-
ties. The Social and Emotional Learning movement supports
the axiom that the cultivation of social and emotional skills to
children is considered crucial for the healthy psychological
adjustment of children and adolescents, as well as for the
development and maintenance of healthy interpersonal
relationships throughout their lives (Ciarrochi and Scott
2006; Elias 1997; Hastings et al. 2000; Koglin and Peterman
2011; Ogden 2001). However, social skills training inter-
ventions by themselves do not improve children’s peer status
or their teacher ratings regarding their behaviour. Rather,
interventions which focus directly on the affective quality of
teacher–student interactions could be a helpful alternative to
skills-training approaches (Hughes et al. 2001).
123
J Child Fam Stud (2015) 24:225–236
At the same time, there is increasing evidence that
teaching parents new parenting skills, tailored to the child’s
needs is a successful intervention for early conduct prob-
lems. Bayer et al. (2008) further postulates that training
programmes must help parents in reducing personal stress,
as well as negative parenting practices. Finally, Cooper and
Jacobs (2011) gives a comprehensive presentation of whole
school interventions for students with emotional and
behavioural difficulties, as well as training programmes for
parents.
Discussion
The rapid developmental changes occurring during tod-
dlerhood and the preschool years entail the potential for
children to experience emotional and or behavioural diffi-
culties. While some preschool children manifest just tran-
sient developmental difficulties and sooner or later ‘‘grow
out’’ of them, there is a large number of children who may
suffer from longstanding difficulties. The recent shift in
research to early childhood problems highlights that early
and persistent problem behaviours consist of a particular
cause of concern, since they may be predictive of future
developmental maladjustment. The state of knowledge
about preschool behaviour however, is quite fragmented in
terms of externalizing and internalizing problems and
uneven (Gardner and Shaw 2008). A good deal of infor-
mation is known about preschool disruptive behaviour and
treatment interventions for this age group. In contrast,
remarkably little clinical or epidemiological research has
examined the characteristics, prevalence or the precursors
of emotional problems in preschool children. Egger and
Angold’s (2006) review of studies on emotional and
behavioural disorders in preschool children, concluded that
we are early in the process of characterizing the nosology
and epidemiology of preschool behavioural and emotional
disorders, particularly depression and anxiety. We are late
though in recognizing the impairment of preschool children
and their families. In fact, very few preschoolers who meet
criteria for a disorder are referred for mental health eval-
uation or receive treatment.
Recent studies exploring the prevalence of problems in
preschool population have documented that increasing
numbers of problems are displayed. However, since there
are no strict diagnostic criteria, they inevitably include
children with both transient problems and those with early-
emerging and more serious problems. Extensive research
has documented the broad patterns of emotional and
behavioural problems and confirmed the considerable sta-
bility of such problems even from a very young age, as
well as the stronger stability for externalizing compared to
internalizing problems. In addition, convergent evidence
J Child Fam Stud (2015) 24:225–236
from different studies confirms that comorbidity between
emotional and behavioural difficulties is high, while early
onset and childhood trajectories characterized by persistent
problems, further increase the risk for later disorders. It is
repeatedly found that early problems that occur in multiple
settings and relationship systems are generally more seri-
ous and stable over time (Kerr et al. 2007). There has also
been increasing recognition of the multiple interacting
factors (biological, environmental, child characteristics)
that contribute to early emotional and behavioural diffi-
culties. Children’s gender differences in the developmental
course of early problems are suggested, the mixed patterns
generally still found in the literature warrant additional
investigation (Meagher et al. 2009). There are concerns in
the literature about distinguishing normal from abnormal
behaviour in this period of rapid change, and the appro-
priateness of using traditional diagnostic categories for
young children. Definition and identification efforts of
emotional and behavioural problems stress that the symp-
toms must be ‘‘developmentally inappropriate’’. Nonethe-
less, no work is provided in the literature to clarify what is
developmentally appropriate or not (Egger and Angold
2006). Acknowledging that rapid developmental changes
makes it hard to set age-appropriate criteria, future work
needs to address criteria or guidelines that specify devel-
opmentally-appropriate manifestations of symptoms and
‘‘true’’ symptoms of disorders. It is argued that there are
disadvantages of not defining EBD in young children,
including failure to recognize distress and provide appro-
priate help (Gardner and Shaw 2008).
The preschool period can be seen as an optimal time to
identify and reduce early signs of problems, before they
develop into permanent patterns. Assessment and inter-
vention efforts have mainly focused on parent–child rela-
tionship (Campbell 1995). Since preschool provides a
promising venue for early screening of children’s emo-
tional and behavioural difficulties, more attention must
now be given to preschool teachers’ perceptions of emo-
tional and behavioural difficulties. Preschool teachers
address students’ emotional and behavioural difficulties as
extremely demanding (Nutbrown and Clough 2004), and
perceive aggression and hyperactivity as more serious and
stable syndromes than withdrawal (Walker et al. 1984).
Taking into consideration preschool teachers’ perceptions
of emotional and behavioural difficulties, is of significant
importance for three reasons: First, it is the case that we
can predict important developmental outcomes in adult-
hood from preschool teachers’ judgments of children with
emotional and behavioural difficulties (Asendorpf et al.
2008). Specifically, for depressive symptoms preschool
teachers play a significant role in identifying early risk of
such symptoms (Meagher et al. 2009). Teachers’ reports of
externalizing problems are useful predictors of later
233
internalizing problems, as well. Secondly, teachers’ per-
ceptions and interpretations of children’s behaviour are
connected to teachers’ behaviour toward the children.
Teachers give more commands to children they perceived
as having more externalizing problems, whereas they give
more praise to children they perceived as having internal-
izing problems (Dobbs and Arnold 2009). Thirdly, in
preschool settings teacher–child relationships have been
shown to be more predictive of children’s positive out-
comes. Negative teacher–child relationships have been
linked to poor behavioural and academic outcomes for
young children and negative attitudes about the school
setting (Dobbs and Arnold 2009). Conflict in the teacher–
child relationship contributed to faster growth in external-
izing behaviour from kindergarten to third grade, and
decreases in children’s prosocial behaviour from kinder-
garten to first grade. On the contrary, children with high
levels of initial aggression, those who were provided
greater teacher support exhibited the largest declines in
aggression across the early school years (Hughes and
Kwok 2006).
Preschool teachers seem to overlook the importance of
emotional and behavioural problems in preschool age.
They attribute such problems to the family and social
environment, whereas they feel less involved in the process
of intervention (Kontopoulou 2003). Teachers are some-
times reluctant to use checklists of psychiatric symptoms to
describe preschool children’s classroom behaviours,
because they want to avoid stigmatizing children with
labels that are not associated with classroom-based services
(Lutz et al. 2002). Early childhood educators need psy-
chometrically sound and culturally appropriate rating
scales of emotional and behavioural problems in order to
accurately identify children with these problems (Fantuzzo
et al. 2001). Research is therefore needed to provide edu-
cators with developmentally appropriate and valid mea-
surements, so that children with difficulties who are still
missed to be captured. We have a limited understanding of
how and where to strategically intervene in the classroom
for EBD children, or how to modify the classroom envi-
ronment to enhance more adaptive children’s behaviour.
Further empirical investigation could inform teacher edu-
cation and school-based prevention and intervention efforts
(Meagher et al. 2009). Research consents that preschool
setting is potentially important for early identification and
intervention programmes delivery for young children with
emotional and behavioural difficulties. Surprisingly, there
is lack of research on preschool educators’ role and com-
petencies or self-efficacy coping with these difficulties and
mainly the emotional ones, which are often under-recog-
nized. This area should be of priority for treatment
research, if these problems are stable and significant from
an early age.
123
234
Limitations
While this study has attempted to be comprehensive in
current research topics of preschool EBD, there may be
recent studies that have not been identified. The literature
in this area is continually informed and new updates occur
frequently. The keyword selection may have missed stud-
ies, and it is possible that the exclusion criteria employed
may mean that some research evidence have not been
included.
Conclusions
Literature review presents substantial research on emotional
and behaviour disorders in preschool children. Although a
good deal is known about disruptive behaviour, little is
known about emotional problems, with poor agreement on
classification and little evidence about causes and treatment.
The ongoing debate about the application of diagnostic cri-
teria for distinguishing normal from abnormal behaviour,
has not resulted in valid diagnostic tools for preschoolers’
emotional and behavioural disorders, employed by educa-
tors. While greater understanding of the identification,
prevalence, aetiology and treatment of EBD will have
implications for research in clinical settings, these advances
are also urgently needed in order to develop educationally
relevant assessment tools and evidence-based treatments.
These tools will enable educators to identify and help pre-
schoolers and their families. In addition, besides the con-
siderable emphasis on preschool setting, in terms of early
identification and prevention of emotional and behavioural
difficulties, there is dearth of research concerning teachers’
role and needs in facing with these difficulties to their stu-
dents. Advances towards this area of research are needed, if
we have to eliminate the continuity of emotional and
behavioural difficulties into later childhood.
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