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Published in final edited form as: Early Child Res Q. 2023 Nov 3;66:245–254. doi: 10.1016/j.ecresq.2023.10.009

Child social-emotional and behavioral problems and competencies contribute to changes in developmental functioning during Early Intervention

Alison E Chavez a, Mary Troxel a, R Christopher Sheldrick b, Abbey Eisenhower a, Sophie Brunt a, Alice S Carter a,*
PMCID: PMC10938922  NIHMSID: NIHMS1942553  PMID: 38495084

Abstract

This study examined how social-emotional and behavioral (SEB) problems and competencies contribute to changes in developmental functioning among children enrolled in Part C Early Intervention (EI), a U.S. program supporting young children with developmental delays and disabilities. The sample included 1,055 children enrolled in EI from 2011–2019 (mean age at EI entry = 17 months; 64% male; 72% marginalized racial and ethnic backgrounds). Standardized developmental assessments, drawn from administrative records, characterized developmental functioning at EI entry and exit and parents reported SEB functioning. Hierarchical regression analyses revealed that SEB problems and competencies interacted in predicting change in developmental functioning from EI entry to exit. Monitoring, identifying, and addressing SEB problems and competencies may optimize developmental outcomes for young children with developmental delays and disabilities.

Keywords: Early Intervention, young children, social-emotional and behavioral functioning, administrative records

1. Introduction

In the United States (U.S.), approximately three percent of children under 36 months of age participate in the federally-funded Part C Early Intervention (EI) program, which provides services and supports to address developmental delays and concerns (Keating et al., 2019; US Department of Education, 2018, 2020). Children in Part C EI are more likely to exhibit elevated social-emotional problems and delays in social-emotional competencies (Briggs-Gowan & Carter, 2008; Thurm et al., 2018). Moreover, many states have identified the social-emotional and behavioral domain as an important target for enhancing service delivery (Smith, Ferguson, Burak, Granja, & Ortuzar, 2020). Greater attention to young children’s social-emotional and behavioral development is critical as it may mitigate the impacts of developmental delays in early childhood. Yet, little is known about the contribution of social-emotional and behavioral problems or delays in social-emotional and behavioral competencies on the developmental gains that children make while in Part C EI. The current study utilizes social-emotional and behavioral screening data from a larger study embedded in three EI agencies (REDACTED FOR PEER REVIEW) to examine associations between parent ratings of toddlers’ social-emotional and behavioral problems and competencies with developmental gains assessed by EI providers using standardized developmental assessment tools as part of routine eligibility, monitoring, and exit developmental evaluations. Understanding the impacts of social-emotional and behavioral well-being on developmental gains for young children in the Part C EI system has the potential to help maximize the effectiveness of EI for participating families and extend the public health reach of this federally funded program.

Over the first years of life, social-emotional and behavioral development unfolds rapidly and sets the foundation for a child’s interactions with others and day-to-day lived experiences (Rosenblum, Dayton, & Muzik, 2009). Challenges or problems in social-emotional and behavioral development (hereafter, “SEB problems”) can arise when emotions and behaviors that are developmentally normative, including aggression, fear, or sadness, are excessive or less frequent and intense than would be developmentally expected. SEB problems can also include atypical challenging behaviors that are not developmentally normative at any age, such as self-injurious behaviors. When SEB problems emerge in early childhood they are often attributed to “being just a phase” (Briggs-Gowan, Carter, Bosson-Heenan, Guyer, & Horwitz, 2006; Mathiesen & Sanson, 2000). However, empirical evidence negates this attribution, suggesting that SEB problems persist through later childhood (Briggs-Gowan & Carter, 2008; Lavigne et al., 1998) and have associations with subsequent challenges in social and academic functioning (Briggs-Gowan & Carter, 2008; Campbell et al., 2006; Gray, Carter, Briggs-Gowan, Jones, & Wagmiller, 2014). Social-emotional and behavioral competencies (“SEB competencies”) refer to behaviors that align with typical milestones in social-emotional and behavioral development, including areas of mastery motivation, prosocial peer relations, and play skills (Carter, Briggs-Gowan, Jones, & Little, 2003; Zeanah & Zeanah, 2018). SEB competencies are theorized to reduce the emergence and persistence of SEB problems (Masten, 2018). With eight to 20% of children younger than five-years-old showing signs of clinically significant SEB problems (Egger et al., 2006; Weitzman, Edmonds, Davagnino, & Briggs-gowan, 2014) and an estimated 32% showing signs of delays in one or more areas of SEB competencies (Briggs-Gowan, Carter, Skuban, & Horowitz, 2001), SEB problems and delays in SEB competencies are common in early childhood.

Delays in SEB competencies and elevated rates of SEB problems are higher in young children with developmental delays (Baker, Fenning, Crnic, Baker, & Blacher, 2007; Sheldrick, Marakovitz, Garfinkel, Perrin, & Carter, 2023; Thurm et al., 2018) and neurodevelopmental disabilities (Baker et al., 2003; van Gameren-Oosterom et al., 2011). In a sample of children receiving Part C EI services, the prevalence of children with elevated SEB problems or low SEB competencies was 60% (Briggs-Gowan & Carter, 2007): a striking majority of the sample and approximately double the estimates observed in the general community. Furthermore, elevated SEB problems and delays in competencies are persistent and linked to later challenges with social development and early educational outcomes (Schlichting, Vivier, Berger, Parrillo, & Sheldrick, 2023). The high rates of SEB problems and delays in competencies among young children in EI, who are already receiving supportive and therapeutic services, suggest that SEB problems and competencies need to be addressed as part of EI services.

Increasingly, there is an interest in expanding EI to better address the social-emotional and mental health needs of infants and toddlers (Smith et al., 2020). This interest coincides with a growing recognition of how social-emotional and behavioral well-being in early childhood can influence long-term developmental outcomes (Zeanah & Zeanah, 2009). However, child social-emotional and behavioral concerns alone are rarely sufficient to qualify children for EI services (Smith et al., 2020). While EI eligibility criteria vary by state, in [REDACTED, location of this study], children between zero and 36 months of age qualify for EI if they 1) have a neurological, genetic, or medical condition, 2) have developmental delay(s) as indicated by scores on the Battelle Developmental Inventory- 2nd Edition in one or more areas of development (e.g., physical development), 3) are at risk for developmental delay(s) given early life history or events that increase likelihood for atypical development, or 4) a clinician determines there is sufficient clinical concern regarding the child’s development (Massachusetts Department of Public Health, 2013). Further, even when clinically significant social-emotional or behavioral concerns are documented (e.g., aggression leading to repeated childcare expulsion), there are no federal recommendations for EI service provisions, with only six states, including (REDACTED; the site of the current report), requiring the use of evidence-based treatment models to address social-emotional and behavioral concerns (Smith et al., 2020). Children receiving EI services have higher SEB problems and delays in SEB competencies than the general population but EI programs are not systematically tracking or addressing these SEB developmental concerns.

Despite EI being an important, longstanding public health service for U.S. children and families, there are challenges to evaluating developmental gains for children in EI. For example, a recent federal report indicated that 65% to 76% of children in EI make “greater than expected” developmental gains in areas related to social, cognitive, and adaptive functioning (ECTA, 2019). Notably, such findings may not be conclusive as they rely on a single group pre-post comparison design, an evaluation method with documented validity problems that may over-estimate intervention effects (Rosenberg, Elbaum, Rosenberg, Kellar-Guenther, & McManus, 2018) and obscure whether gains can be attributed to EI services or other factors (e.g., child’s rate of growth or maturation). Thus, while there is some support for “greater than expected” developmental gains for children in EI, little is known about the extent to which SEB problems and competencies may contribute to developmental gains for young children receiving these services.

An understanding of the contextual or social position factors that contribute to child developmental gains in EI is important as it has the potential to guide screening, evaluation, and intervention practices. From an integrative model framework (García Coll et al., 1996), accounting for child characteristic and family social position variables allows us to clarify developmental competencies for young children and families from currently and historically marginalized racial and ethnic backgrounds. Contextual factors may include child and family characteristics that elucidate for whom the EI system is effective. For instance, older child age at EI entry has been associated with greater developmental gains while in EI (Richardson et al., 2020). Further, in community samples of young children, sex differences have been identified such that males have lower SEB competence than females (Briggs-Gowan et al., 2001), pointing to another characteristic that may impact developmental progress in EI services. Other factors such as family race, ethnicity, and household language are social determinants of health that may be indirectly associated with developmental gains. For example, research has identified racial disparities in EI services receipt such that Black young children are less likely than their White peers to receive EI services (Feinberg, Silverstein, Donahue, & Bliss, 2011; Rosenberg, Zhang, & Robinson, 2008). Documenting the contributions of child SEB problems and competencies to developmental gains in the context of child and family factors may aid in supporting efforts to increase attention on SEB problems and competencies in the EI system.

1.1. Current Study

The aim of the current study was to determine the extent to which SEB problems and competencies are associated with changes in developmental functioning over the course of children’s time in the Part C EI system. This study uses the term SEB ‘problems’ in order to align with the language used in Brief Infant-Toddler Social and Emotional Assessment (BITSEA; Briggs-Gowan, Carter, Irwin, Wachtel, & Cicchetti, 2004), which is the measure of SEB functioning used in this study, and to align with literature focused on SEB functioning in early childhood (e.g., Gleason, Goldson, & Yogman, 2016; Holland, Malmberg, & Gimpel Peacock, 2017). Informed by an ecological developmental framework (Bronfenbrenner, 1994) alongside an integrative model framework (García Coll et al., 1996), this study examined the contribution of SEB problems and competencies to changes in developmental functioning in the context of child and family factors. EI programs included in the current study used a single instrument to assess developmental functioning at EI entry and exit. Parent ratings of SEB problems and competencies gathered as part of a screening study were merged with state records of child developmental functioning and demographic information for children enrolled in EI to examine how SEB problems and competencies contributed to changes in children’s developmental functioning from EI entry to follow-up, often measured at time of exit from EI. We hypothesized that elevated SEB problems during enrollment in EI would be associated with smaller gains in developmental functioning from EI entry to follow-up, whereas higher SEB competencies would be associated with greater gains in developmental functioning from EI entry to follow-up, over and above child and family covariates. We also hypothesized that SEB competencies would play a protective role by moderating the association between SEB problems and gains in developmental functioning. Finally, to examine developmental outcomes through the lens of clinical practice, in which established cut scores are used to document dichotomous screening outcomes (i.e., clinically concerning score or not), we compared changes in developmental functioning from EI entry to follow-up across the following four groups: (1) “no elevated SEB problems or delays in competencies,” (2) “possible elevated SEB problems,” (3) “possible delayed SEB competencies,” and (4) “elevated SEB problems and delayed competencies.” Understanding the effect of SEB problems and competencies on developmental gains for children in EI is vital to developing strategies to enhance the effectiveness of EI and identifying ways to support positive child and family outcomes.

2. Methods

2.1. Participants

Participants included in this report had SEB screening as part of their routine EI practice, concurrent with their agency partnering in a study to promote early detection of autism (REDACTED), which was conducted at three Part C EI agencies in (REDACTED) from 2013 to 2019. Agencies provided data on SEB screening results that could be linked to data on EI service utilization, child and family demographic characteristics, and developmental functioning, which were obtained from (REDACTED – STATE AGENCY). Children and their families were eligible for the screening study if they: (a) received EI services for at least eight weeks, (b) were aged 14 to 36 months at the time of SEB screening, (c) did not already have an ASD diagnosis, (d) did not have a medical complexity (e. g., blindness, fragile health) that would prevent completion of a play-based screener, and (e) had a caregiver who could complete screening forms in either English or Spanish. Further, for inclusion in the current report, children had to a) be under 30 months of age upon EI enrollment (to allow at least six months between EI entry and exit) and b) have received a follow-up developmental evaluation (either at EI exit or midenrollment) through their EI program. Participants with missing values for date of birth (n = 1) or for both of our key predictors (SEB Problems and Competencies; n = 6) were excluded.

The sample for this report includes 1,055 children. A majority of children were boys (63.5%), from Black, Indigenous, People of Color (BIPOC) or White Latinx (72.4%), had a primary household language of English (67.4%), and had public insurance (59.7%). On average, children were 17 months of age at the time of entry to the EI program, 30 months of age at the time of exit from the EI program, and had 13 months in between entry and follow-up evaluations. Of note, 17% of children in this sample had a documented ASD diagnosis and a majority of children in this sample (77.5%) qualified for EI based on established delays. Detailed participant demographic characteristics and EI service information are described in detail in Table 1.

Table 1.

Demographic characteristics for sample (N = 1,055).

Demographic Variables % or M(SD) Range
Child level factors
Child sexs
Female (n = 385) 36.5 —
Male (n = 670) 63.5 —
Child age at entry to EI, in months 17.0 (5.1) 1–30
Child age at exit from EI, in months 29.9 (4.1) 14–36
Family level factors
Family race/ethnicity
Asian (n = 49) 4.6 —
Black (n = 261) 24.7 —
Latinx, Black (n = 62) 5.9
Latinx, multiethnic/multiracial (n = 27) 2.6
Latinx, other/unspecified (n = 61) 5.8 —
Latinx, White (n = 231) 21.9
Multiracial/multiethnic (n = 38) 3.6 —
White, non-Latinx (n = 322) 30.5 —
Missing (n = 4) 0.4 —
Primary household language
English (n = 711) 67.4 —
Spanish (n = 180) 17.1 —
Other (n = 164) 15.6 —
Insurance
Private (n = 391) 37.1 —
Public (n = 580) 55.0 —
Missing (n = 84) 7.9
Child EI Eligibility Reason
Established conditions 2.0
Established delays 77.5
At-risk for a condition(s) 2.4
Established condition and established delay 4.6
Established condition and at-risk for other condition (s) 0.2
Established delay and at-risk for other condition(s) 9.1
Established condition, established delay, and at-risk for other condition(s) 0.6
Clinical judgement 3.2
Unknown 0.4
EI service system factors
Time elapsed between entry and follow-up Battelle assessments, in months 12.9 (3.7) 2–34
Time elapsed between entry (Battelle) and SEB (BITSEA) assessments, in months 5.2 (3.6)
Time elapsed between SEB (BITSEA) and follow-up (Battelle) assessments, in months 7.7 (4.0)
Total child intervention hours received through EI 114.4 (130.3) 3–1606
Child intervention hours received per week through EI 2.0(1.9) 0–13
SEB Functioning (BITSEA)
Problem Score 11.0 (8.0) % above clinical cut off: 29.5%
Competence Score 15.3 (4.2) % below clinical cut off: 36.8%
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Abbreviations: EI = Part C Early Intervention; BITSEA = Brief Infant-Toddler Social and Emotional Assessment; SEB = social-emotional and behavioral

2.2. Measures

2.2.1. Social-Emotional and Behavioral Problems and Competencies

The Brief Infant-Toddler Social and Emotional Assessment (BITSEA; Briggs-Gowan & Carter, 2006) is a nationally normed standardized screening tool, designed to assess SEB problems and competencies in children ages 12 to 36 months old. A 42-item parent-report questionnaire, the BITSEA generates two continuous scores: Problem Total and Competence Total as well as providing “Possible Problem or Delay” screening cut scores in each domain by age and sex. The Problem scale consists of externalizing problem, internalizing problems, and dysregulation problems. Example Problem items include “seems nervous, tense, or fearful” and “hits, bites or kicks.” Example Competence items include “follows rules” and “shows affection with loved ones.” All items are rated on a scale of 0 (“not true or rarely”) to 2 (“very true or often”) such that higher scores indicate greater levels of SEB problems and competencies. The Spanish version of the BITSEA was provided to Spanish-speaking families in this study.

The BITSEA has shown strong psychometric properties (Briggs-Gowan et al., 2004), including with low-income Spanish speaking parents (Hungerford, Garcia, & Bagner, 2015) and has been used with children enrolled in EI (Briggs-Gowan & Carter, 2007). Internal reliability in this sample was high for the Problem scale (α = .81) and satisfactory for the Competence scale (α = .58). In this study the BITSEA Problem and Competence Total raw scores were used to characterize children’s SEB problems and SEB competencies. To address clinical practice implications, we created four SEB problem and competence groupings that were determined by “Possible Problem or Delay” scores in the Problem and Competence domains. The four groupings were: (1) “no elevated SEB problems or delays in competencies,” (2) “possible elevated SEB problems,” (3) “possible delayed SEB competencies,” and (4) “possible elevated SEB problems and delayed competencies.” “Possible Elevated Problem” scores are higher than the clinical threshold (i.e., more problems) whereas “Possible Delayed Competence” scores are lower than the clinical threshold (i.e., fewer competencies). Clinical thresholds were determined based on nationally normed standard age- and sex-based cutoffs.

2.2.2. Child Developmental Functioning

The Battelle Developmental Inventory – Second Edition (“Battelle”; Newborg, 2005) is used with children ages zero through seven years and 11 months to evaluate child functioning in five developmental domains: adaptive, personal-social, communication, motor, and cognitive skills. The Battelle identifies child developmental strengths and deficits and is administered through structured activities, child observations, or parent interviews. Items on the Battelle are rated on a three-point scale ranging from skills not displayed by the child (score = 0) to skills that are present and developed (score = 2). Raw scores of each subdomain are calculated into scaled scores, then added up to make the domain sum, which is then converted to a standard score, termed “Developmental Quotient” (DQ), and percentile rank. Domain sums are added together to calculate the total score, which is also converted to an overall DQ and percentile rank. DQs range from 55 to 145, with lower scores indicating greater developmental deficits. Psychometric properties of the Battelle, such as internal consistency and reliability range from adequate to strong according to its authors (Alfonso, Rentz, & Chung, 2010; Newborg, 2005); however, independent evaluations of the Battelle’s psychometric properties have not been conducted (Cunha, Berkovits, & Albuquerque, 2018). The Total DQ on the Battelle was used to characterize children’s developmental functioning at EI entry and at a later time point. For children in this study who did not have an exit Battelle (e.g., moved out-of-state or dropped out of EI), the most distal Battelle administration (n = 635; 60.2%), usually conducted to monitor developmental progress and determine continued EI eligibility, was used as a proxy for the exit Battelle; therefore, in this study we use follow-up developmental functioning to refer to either developmental functioning at the time of exit from EI or at the most distal recorded developmental evaluation from the time of EI entry.

2.2.3. Child and Family Covariates

The child covariates included were child’s sex and age at the time of EI entry. Family covariates included family race and ethnicity and primary household language. Child and family demographic variables were collected by EI sites.

2.3. Procedure

This study involved an analysis of administrative data from the Department of Public Health and screening data collected as part of a larger screening initiative (REDACTED). The Battelle was administered to children by trained EI providers as part of clinical routine practice at individual EI agencies to determine EI eligibility (“entry developmental functioning”). The BITSEA was completed by parents and caregivers (“parents”) as part of the first stage in the larger study’s screening and diagnostic evaluation protocol. Access to the administrative dataset was approved by the (REDACTED). Research study protocols were approved by both (REDACTED) and (REDACTED) Institutional Review Boards.

2.4. Analytic Strategy

Descriptive statistics were conducted for developmental functioning domains (Battelle), SEB problems and competencies (BITSEA), and child and family covariates. Rates and patterns of missingness were explored for key variables. Prior to conducting our main analyses, we conducted paired sample t-tests of Battelle entry and follow-up DQ Total standard scores to describe the unadjusted patterns of children’s developmental change over time. Within these analyses, we examined the full sample generally and differentiated by SEB problems and competence groupings. Significant gains in Battelle DQ scores would suggest that children are improving relative to their peers at a rate greater than would be expected within the interval between assessment points.

Next, our main goal was to determine whether change in developmental functioning was associated with SEB problems, SEB competencies, and the interaction of SEB problems and competencies, after controlling for the potentially confounding effects of child and family covariates. The inclusion of intervention hours as a service covariate was considered. However, given that EI hours were associated with both the dependent and independent variables, and given the temporal order of these variables, intervention hours met the conceptual definition of a mediator—not of a confounder. The inclusion of mediators in regression analyses reduces the association between the independent and dependent variables (Baron & Kenny, 1986). Intervention hours was thus not included in the regression model.

SEB problems and competencies were centered to facilitate interpretation. We employed a hierarchical (or sequential) multiple regression analysis. In model 1, we entered developmental functioning (Battelle) so that the residual in the predicted follow-up Battelle DQ score would represent change in developmental functioning. Next, based on our theoretical hypotheses and an integrative developmental framework, we introduced child and family covariates in two separate models to evaluate the respective impacts of child (Model 2: child sex, age at EI entry) and family (Model 3: family race and ethnicity and primary household language) covariates. Categorical covariates were dummy coded to compare boys (coded 1) to girls (coded 0), families of color including White Latinx families (coded 1) to White non-Latinx families (coded 0), and families from households where the primary language was not English (coded 1) to those in primarily English-speaking households (coded 0). Child age in months at EI entry was examined as a continuous covariate. In model 4, we entered SEB problems (BITSEA Problem Total score, with higher scores reflecting greater problems). In model 5, we entered SEB competencies (BITSEA Competence Total score, with higher scores reflecting greater competencies). The interaction between SEB Problems and Competencies was entered to explore moderation (model 6).

Lastly, to inform clinical practice, we examined the effect of screening positive versus negative in the Problems and Competence BITSEA domains on children’s change in developing functioning. BITSEA Problem and Competence cut scores were used to identify children with SEB Problems and Competence scores that were in the “Possible Problem or Delay” range. We conducted a repeated measures analysis of variance (ANOVA) to examine the effect of dichotomous screen positive versus negative SEB Problem and Competence groupings as a between-subjects factor on change in developmental functioning from entry to follow-up (within-subjects factor). These analyses did not include child, family, and service covariates as they were intended to represent the way BITSEA cut scores are used in clinical practice. Analyses were conducted in Stata Version 16 (StataCorp, 2015).

3. Results

Data was 98% complete. Given low levels of missingness for key variables (N = 21; n = 0 for child sex, age, and primary language; n = 4 for race and ethnicity; n = 3 for BITSEA competencies; n = 15 for BITSEA problems out of 1,055 cases), we opted for listwise deletion rather than multiple imputation.

3.1. Change in Developmental Functioning from Entry to Follow-up

Change in Battelle DQ standard scores (at entry and follow-up) overall and by SEB problems and competence groupings are presented in Table 2. Overall, 48% of children demonstrated scores in the “Possible Problem or Delay” range for SEB problems, competencies, or both domains. Table 2 also summarizes the results of the paired sample t-tests examining developmental change during children’s time in EI.

Table 2.

Change in developmental functioning for full sample and by clinically concerning SEB problems and competencies groupings.

Total Battelle Developmental Quotient (DQ) N (%) Entry M (SD) Follow-up M (SD) t df Cohen’s d
Full sample 1055 (100%) 77.96 (10.76) 83.82 (15.04) 15.00** 1054 0.448
No elevated SEB problems or delays in competencies † 552 (52.3%) 81.96 (9.67) 90.47 (12.94)a,c 15.13** 511 0.745
Possible elevated SEB problems † 115 (10.9%) 78.45 (9.29) 84.57 (11.60)a,c 5.89** 114 0.582
Possible delayed SEB competencies † 192 (18.2%) 73.78 (9.79) 76.68 (13.68)b,c 3.52** 191 0.243
Elevated SEB problems and delayed competencies † 196 (18.6%) 70.48 (9.11) 71.63 (12.77)b,d 1.44 195 0.104
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†

Determined using BITSEA cut scores for possible problem or possible deficit/delay that account for child age and sex

**

p < .01

Abbreviations: DQ – Developmental Quotient; SEB – social-emotional and behavioral

Note: Statistical differences (p< .05) in mean rates of change in developmental functioning between SEB groups according to repeated measures ANOVA tests are indicated by different subscripts in the “Follow-up” column.

Generally, paired t-tests analyses revealed statistically significant gains in scores from entry to follow-up developmental functioning for the Total Battelle DQ in the full sample and for three of the four SEB problem and competence groupings. With the exception of the group showing elevated SEB problems and delayed competencies, where there was a small but non-significant increase in scores, children made statistically significant developmental gains overall and across groups during their time in EI.

3.2. Associations between Developmental Functioning, Child and Family Covariates, and SEB Problems and Competencies

SEB competencies and SEB problems were significantly negatively correlated, r(1,037) = −.47, p < .001). Correlations among other key study variables are presented in Supplemental Table A. Given that multicollinearity between regression variables can result in unstable coefficients and inflated standard errors, analyses to determine the variance inflation factor (VIF) were conducted in model 5 to assess for multicollinearity (Thompson, Kim, Aloe, & Becker, 2017). Concern regarding multicollinearity is typically raised for VIF scores above 10 (Thompson et al., 2017); there was no evidence for multicollinearity bias as all VIF scores were below 2, with a mean of 1.29. Correlations between the Battelle subdomains and BITSEA subscales are presented in Supplemental Table B.

Results of the hierarchical multiple regression model are presented in Table 3, including model R2 statistics and relative change for each model. Generally, variables added in each model accounted for additional unique variance relative to the prior models. In model 1, entering developmental functioning significantly explained 31% of the variance in follow-up developmental functioning, F(1, 1053) = 478.76, p <.001. In model 2, child sex and age at EI entry each significantly predicted change from entry to follow-up developmental functioning, accounting for an additional 3% of the variance, F(3, 1051) = 183.89, p < .001. Specifically, smaller gains in developmental functioning were made by boys relative to girls and by children who entered EI at older ages. In model 3, family covariates significantly predicted change from entry to follow-up developmental functioning, such that smaller gains were made when families were from marginalized racial and ethnic backgrounds relative to White and when families had a primary language other than English, F(5, 1045) = 132.35, p < .001. The addition of family covariates accounted for an additional 4% of the total variance. In model 4, SEB problems significantly predicted follow-up developmental functioning, F(6, 1030) = 119.14, p < .001, accounting for an additional 2% of the variance. Greater problems were associated with smaller gains in developmental functioning. Each of the child and family covariates continued to significantly contribute to the model. In model 5, SEB competencies significantly predicted follow-up developmental functioning, accounting for an additional 7% of the variance. Fewer competencies were associated with smaller gains in developmental functioning.

Table 3.

Summary of hierarchical regression: Predicting developmental functioning (Battelle DQ) at the time of exit from Part C Early Intervention (EI) services.

Variables Entered Model 1 β (SE) Model 2 β (SE) Model 3 β (SE) Model 4 β (SE) Model 5 β (SE) Model 6 β (SE)
Constant (intercept) 83.82** 91.76** 95.90** 94.28** 95.35** 94.93
Entry developmental functioning (Battelle DQ) .56 (.04)** .53 (.04)** .50 (.03)** .45 (.04)** .33 (.04)** .33 (.04)**
Child’s sex (0 = female, 1 = male) −.14 (.79)** −.15 (.77)** −.14 (.76)** −.11 (.72)** −.11 (.72)**
Age at EI entry, in months −.10 (.07)** −.09 (.07)** −.07 (.07)** −.10 (.07)** −.11 (.07)**
Family race and ethnicity (0 = White, non-Latinx, 1 = BIPOC) −.18 (.83)** −.16 (.83)** −.16 (.78)** −.15 (.79)**
Primary household language (0 = English, 1 = not English) −.07 (.83)* −.05 (.81)* −.05 (.77)* −.05 (.77)*
SEB problems (BITSEA) −.17 (.05)** −.06 (.05)** −.08 (.05)**
SEB competencies (BITSEA) .32 (.10)** .32 (.10)**
Interaction term: SEB problems × competencies −.06 (.01)*
R2 at each step .313** .344** .388** .410** .476** .479**
Adjusted R2 at each step .312** .342** .385** .406** .472** .475**
Δ R 2 .032** .044** .022** .066** .003*
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*

p < .05,

**

p < .01

Abbreviations: ASD – Autism spectrum disorder; BIPOC – Black, Indigenous, People of Color; BITSEA – Brief Infant Toddler Social and Emotional Assessment; DQ – developmental quotient; EI –Early Intervention; SEB – social-emotional and behavioral

In the final (model 6), we examined the potential interaction between SEB Problems and Competencies. The interaction term was significant, accounting for an additional 0.3% of the variance. The final model (model 6) accounted for 48% of the variance in follow-up developmental functioning, F(8, 1025) = 117.62, p < .001. Each of the covariates remained significantly associated with reduced gains in developmental functioning at EI follow-up, including: being a boy, older age at EI entry, marginalized family race or ethnicity, and households with primarily languages other than English.

Fig. 1 illustrates the significant interaction effect by plotting predicted values of exit developmental functioning at different values of SEB problems and competencies. There was a stronger association between competence and gains in DQ standard scores for children with low SEB Problems as compared to those with elevated SEB Problems. Comparable findings are observed in the analyses comparing SEB Problem and Competence groupings.

Fig. 1.

Fig. 1.

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Adjusted Developmental Quotient (DQ) at follow-up given interaction between social-emotional and behavioral (SEB) problems and SEB competencies at baseline

Note. Developmental quotient (DQ) at follow-up was measured using the Battelle Developmental Inventory. Social-emotional-behavioral problems and competencies at baseline were measured using the Brief Infant Toddler Social Emotional Assessment. Adjusted values account for baseline DQ scores and demographic variables.

3.3. Developmental Functioning by SEB Problem and Competence Groupings

Results of the repeated measures ANOVA, which were conducted to examine the effect of screening positive versus negative for SEB problems and competencies on change in developmental functioning, indicated a main effect of time such that developmental functioning significantly increased from entry to follow-up, F(1, 1051) = 110.21, p < .001. Results also indicated a main effect of SEB groupings such that groups significantly differed by developmental functioning, F(3, 1051) = 147.24, p < .001. However, there was an interaction between time and SEB groupings, F(3, 1051) = 21.69, p < .001 (see Fig. 2 and Table 2), suggesting that SEB problem and competence groups varied in the degree to which they gained in DQ over time in EI. Children with no elevations in either SEB problems or competencies increased in developmental functioning from entry to follow-up significantly more than children in the “possible delayed SEB competencies” group, F(1, 3) = 16.77, p < .001, and the “elevated SEB problems and delayed competencies” group, F(1, 3) = 29.97, p < .001, but did not differ from the children in the “possible elevated SEB problems” group, F(1, 3) = 2.15, p = 0.14. Children in the “possible elevated SEB problems” group increased significantly more than children in the “elevated SEB problems and delayed competencies” group, F(1, 3) = 7.24, p = .01 and were not significantly different from the “no elevated SEB problems or delays in competencies” group (reported above) or the “possible delayed SEB competencies” group F(1, 3) = 2.85 p = 0.09. Children in the “possible delayed SEB competencies” group did not have a significantly different rate of change from children in the “elevated SEB problems and delayed competencies” group, F(1, 3) = 1.10, p = .30, or children in the “possible elevated SEB problems” group (reported above). On average, children for whom BITSEA scores indicated no concerns for problems or competencies gained 8.5 points in DQ by the time they left EI (approximately .5 of a standard deviation). In contrast, children for whom BITSEA scores indicated concerns for both problems and competencies gained 1 point in DQ by the time they left EI. As reported in Table 2, the “elevated SEB problems and delayed competencies” group was the only group that did not show statistically significant gains during their time in EI. They did not fall behind relative to the normative peer group, but in contrast to the three other groupings, they did not show gains.

Fig. 2.

Fig. 2.

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Change in Battelle scores from entry to follow-up by SEB problems and competencies groupings.

4. Discussion

The current study leveraged administrative data from Part C Early Intervention (EI) alongside social-emotional and behavioral research screening data to examine how young children’s SEB problems and competencies predict the degree of developmental gains achieved during EI enrollment. The majority of children in our sample who were enrolled in Part C EI made gains in developmental functioning from EI entry to follow-up. These gains reflect not only an increase in developmental skills and abilities that would be expected as children age (i.e., maturation), but given the use of age-normed scores, they also reflect greater gains than would be expected for an age-matched peer within the time interval between entry and follow-up. Specifically, on average, children gained 5.86 points (standard deviation = 12.7) in their total Battelle developmental quotients (DQ). These findings suggest that on the whole children receiving EI services achieved gains that exceeded developmental expectations during the period in which they received EI services. When gains were assessed according to social-emotional and behavioral (SEB) problem and competence groupings, children with possible elevated SEB problems or possible delayed SEB competencies, showed smaller gains than those with scores that indicated no possible problems or delays. Of note, only children who were rated by caregivers as demonstrating “Possible Problem or Delay” scores in both SEB problems and competencies did not make statistically significant developmental gains, gaining an average of one DQ point during their time in EI, relative to those with no elevated or delayed SEB scores who gained an average of eight and a half points. These findings strongly suggest that engaging in interventions addressing SEB problems and delays in competencies as part of Part C EI intervention programming might enhance developmental gains.

There was also continuity in children’s developmental functioning across their time in EI. The developmental functioning (i.e., measured by Battelle scores) that children presented with upon entry to EI accounted for approximately 30% of the variance in their follow-up developmental functioning. On the other hand, regarding the degree of change over time, this moderate level of stability suggests that there is considerable variability in the degree of gains among children in EI.

In terms of SEB well-being, almost half (48%) of children were in the “Possible Problem or Delay” range for SEB problems, competencies, or both domains during their enrollment in EI. In this sample of children who were screened as part of routine practice (REDACTED), 29.5% exceeded the cut-off for problems, 36.8% for delays in SEB competencies and 18.6% had clinically significant scores for both problems and competencies. These high rates are consistent with previous research documenting increased likelihood for SEB problems and delays in SEB competencies in children in EI (e.g., Briggs-Gowan & Carter, 2007). One mechanism that may underlie the association between SEB problems and developmental delays and disabilities is that behavioral problems may serve as an alternative to verbal communication, such as an expression of typical toddler assertion of autonomy, frustration, or self-protectiveness. In addition, language delays—the most common form of developmental delay for children enrolled in EI—may lead children to disengage from interactions because they are less able to express their needs, wants, and desires (Irwin, Carter, & Briggs-Gowan, 2002), minimizing opportunities to acquire SEB competencies.

While the high rates of SEB problems and delays in competencies in this sample are not surprising, they are noteworthy considering the myriad domains of child and family life impacted by poor SEB well-being, including child mental health disorder status (Briggs-Gowan & Carter, 2008; Domitrovich et al., 2017), increased parenting stress (Estes et al., 2009; Meppelder, Hodes, Kef, & Schuengel, 2015), and a reduction in a family’s ability to participate in routines of daily life (Crnic, Hoffman, Gaze, & Edelbrock, 2004; Mian, Soto, Briggs-Gowan, & Carter, 2018). Findings from the current study support recommendations for identifying SEB problems and delays in the acquisition of competencies in EI (Smith et al., 2020). In addition to targeted intervention, the routine use of validated social-emotional and behavioral screening tools may be a valuable opportunity for EI providers to identify the strengths and challenges in this specific developmental domain that can have downstream effects on children’s broader functioning. There is strong evidence that EI providers can successfully use SEB screening tools in community EI settings (Eisenhower et al., 2020). Future research could evaluate ways to implement routine social-emotional and behavioral screening and interventions in EI and how these practices correspond with young children’s development and family engagement.

Our primary findings are that SEB problems and competencies are associated with changes in developmental functioning over time while children are receiving EI services and the presence of SEB problems appears to moderate associations between SEB competence and gains in developmental functioning in EI. Specifically, child SEB problems predicted reduced gains in developmental functioning from EI entry to follow-up, taking into consideration contextual child and family factors (which together accounted for 41% of the variance). Moreover, it is important to consider both SEB problems and competencies together, as children with elevated SEB problems and delayed SEB competencies showed the fewest gains in developmental functioning. A plausible explanation for these findings is that when children have lower SEB competencies, including the capacity to maintain attention to objects or show interest in reciprocal social interactions, EI providers may have difficulty creating learning opportunities during EI sessions. Similarly, elevated SEB problems may interfere with potential learning opportunities during EI sessions as providers may then need to spend time managing challenging behaviors. Indeed, extant research has identified that delays or deficits in competencies may increase the risk for subsequent behavioral problems (Denham, Blair, Schmidt, & DeMulder, 2002, 2003), and that SEB competencies may be protective for continued competence later in childhood (Baker et al., 2007). Our finding that there was a stronger association between SEB competencies and gains in developmental functioning for children with low SEB problems (versus those with elevated SEB problems) points towards the need to use a strengths-based approach to intervention by identifying competencies and continuing to bolster them during intervention.

Anecdotally, in our collaboration with EI programs for this research study, EI providers voiced concerns about how child SEB problems—especially challenging behaviors, such as aggression and tantrums—interfered with their ability to implement interventions. Many providers shared that they felt they did not have enough training or confidence to address SEB problems. Although one may assume that SEB problems, and not competencies, would be a greater concern for learning, our findings suggest it is possible for both competencies and problems to become significant barriers to learning and growth in EI. In our sample SEB problems and competencies were moderately, negatively correlated (r = −.47) and 19% of children had scores above clinical cut-offs in both SEB domains. A future direction for researchers is to systemically assess how EI providers can effectively collaborate with families to identify and implement intervention goals focused on promoting SEB development, while also addressing children’s other areas of concern and fostering children’s strengths.

In clinical practice, providers rely on cut-off scores to determine whether children are above or below the risk threshold; we examined how such dichotomous cut-off scores for SEB problems and competencies were associated with children’s developmental functioning over time. We found that children’s developmental gains during EI differed based on whether they had clinically significant problems or competencies, or both. Notably parents’ ratings of children’s SEB problems and competencies were associated with developmental functioning such that children whose scores were in the “Possible Problem or Delay” range for both SEB problems and competencies had the lowest developmental functioning at entry and follow-up and children with no problem or delayed scores in either SEB domain had the highest developmental functioning. Importantly, the difference in Battelle DQ scores between these two groups increased over time from entry to follow-up (see Fig. 2). In addition, children in the “elevated SEB problems and delayed competencies” group fared worse in terms of developmental gains than other groups. These findings provide insight into the impairment that can result from co-occurring SEB problems and delays in SEB competencies when young children already have or are at risk for a developmental delay or disability.

Beyond documenting the developmental gains of children in EI, our findings also highlight how child and family factors contribute to developmental gains for young children in EI. From an integrative model of development (García Coll et al., 1996), our findings suggest that child characteristics and family social position factors are important to account for in tracking developmental gains, as each of these levels were significantly associated with the gains, respectively contributing an additional 3% and 4% to the total observed variance. Specifically, boys, who comprised a higher percentage of the total sample (63.5%) made smaller developmental gains than girls. In addition, children who entered EI at an older age made fewer gains than those who entered at an earlier age, which may reflect less time in EI or other factors that may reduce initial and ongoing access to service receipt.

With regard to family factors, there appear to be disparities in the efficacy of EI. Specifically, when families were from marginalized racial and ethnic backgrounds relative to White families and when families had a primary household language other than English, children evidenced smaller developmental gains. These family-level contributors to gains while children are in EI reflect systemic inequities, not deficits in children from marginalized racial, ethnic, and linguistic backgrounds. Moreso, the disparities in who makes developmental gains in EI call for an urgent need to enhance culturally informed and linguistically accessible family-centered care. In line with an integrative model of development (García Coll et al., 1996), these findings underscore how child characteristics and family social position variables can be mediated through inequitable environments that ultimately contribute to developmental competencies. Families from marginalized racial and ethnic backgrounds are more likely to report negative first experiences with EI (Bailey et al., 2004), and Spanish-speaking families (versus English-speaking ones) have self-reported lower child and family EI-related outcomes and lower perceptions of the helpfulness of EI (Olmstead et al., 2010). It is plausible that cultural misunderstandings, assumptions of family deficit, and providers’ biases are barriers to the care linguistically, racially, and ethnically diverse families receive in EI (Harry, 2008). In addition, interactions between parents and help-giving systems may impact child developmental outcomes by inadvertently shaping family engagement (Guralnick, 2011). More research is needed on how to re-engage and support linguistically, racially, and ethnically diverse families who may have had these negative experiences.

4.1. Limitations

The current study has many strengths, including the large, diverse sample of families who participated. In addition, unlike previous studies on EI that relied solely on parent-reported child developmental outcomes, this study made use of administrative records to operationalize child developmental functioning in a way that reflected current practices within the Part C EI system and that is replicable in research settings (e.g., use of validated assessment tools for developmental functioning and social-emotional and behavioral well-being). Another limitation of the current study is that developmental assessment data at EI exit was not available for 60% of children in the sample. This could be because they moved away or exited EI abruptly. For these children, we used an earlier, follow-up developmental assessment, conducted an average of 12.9 months after enrolling in EI, as a proxy of exit assessment which could have altered findings. Finally, there is a lack of consensus about which developmental measures to use for assessing developmental gains in EI (Hebbeler, Barton, & Mallik, 2008). The current study was possible in Massachusetts because all EI providers are trained to use the same nationally normed and standardized instrument for developmental assessment (i.e., Battelle) and scores are maintained in a state-wide database. Despite its widespread use in EI (Lee, Bagnato, & Pretti-Frontczak, 2016) and in clinical research (e.g., Goldin, Matson, Beighley, & Jang, 2014; Sipes, Matson, & Turygin, 2011), the Battelle has not been independently evaluated for its psychometric properties (Cunha et al., 2018), including its cultural and linguistic validity, which may limit the validity of our findings.

Further, we only had one assessment of SEB problems and competencies and this assessment was not always proximal to EI entry (mean time between EI entry and SEB assessment was 5.2 months), as some children entered EI prior to being 14 months old, which is the age at which SEB assessments were conducted as part of the larger study. Future research could model how changes in SEB well-being covary with gains in developmental functioning. The internal reliability of the BITSEA Competence scale (α = .58) is another a limitation of this study. Given that most children in this sample have developmental delays, there may be a more restricted range within many of the competence items (i.e., reduced variance), which in turn would reduce internal consistency. Despite this, the SEB competence scale is providing meaningful information as it accounts for significant variance in our outcome of interest. Moreover, it is worth noting that the Battelle includes social-emotional indicators in a subscale (i.e., Personal/Social domain); however, the overlap between this subscale with the measure of SEB functioning likely did not skew results (see Supplemental Table B for correlations between measures). One other limitation regarding assessments is that this study used a single-method and/or a single-informant for each of the constructs measured (i.e., SEB functioning and developmental functioning). Although the BITSEA reportedly has high parent-professional interrater reliability (Briggs-Gowan et al., 2004), future research may want to examine SEB and developmental functioning while also accounting for concordance in ratings from parents and providers. The use of parent ratings in this study presents a family-centered approach to the measurement of SEB well-being.

5. Conclusion

The primary aim of this study was to examine associations between young children’s social-emotional and behavioral problems and competencies with developmental gains while in Part C Early Intervention. Consistent with previous research, we identified elevated SEB problems and delays in competencies in our sample, emphasizing the need for EI services that can effectively target these domains in a family-centered approach. Further, social-emotional and behavioral problems and competencies predicted change in developmental functioning from EI entry to follow-up. The current study findings also underscored the contributions of child and family factors that contributed to developmental gains, revealing groups of families that may benefit from additional supports. Findings from this study suggest that screening for, identifying, and addressing child SEB problems and competencies in EI may be one way to optimize child developmental outcomes.

Supplementary Material

1

Funding Acknowledgments

This project was supported by the National Institutes of Mental Health (R01 MH104400-01) and the Health Resources and Services Administration of the U.S. Department of Health and Human Services (R40MC26195).

Footnotes

CRediT authorship contribution statement

Alison E. Chavez: Formal analysis, Methodology, Writing – original draft, Conceptualization. Mary Troxel: Formal analysis, Methodology, Writing – original draft, Conceptualization. R. Christopher Sheldrick: Formal analysis, Methodology, Funding acquisition, Conceptualization. Abbey Eisenhower: Methodology, Funding acquisition, Project administration, Conceptualization. Sophie Brunt: Data curation, Formal analysis. Alice S. Carter: Conceptualization, Data curation, Methodology, Funding acquisition, Project administration.

Supplementary materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ecresq.2023.10.009.

Data Availability

The authors do not have permission to share data.

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