The present study shows that assessment of the child's behavior by parents and preschool teachers using the SDQ, teachers' assessment of engagement and social interaction using the CEQ, and the CHC psychologist's assessment of the child's psychosocial health using LillaLAPS largely agree, in terms of the child's mental health, behavioural problems and everyday function. The results also highlight the importance of considering the parents', the preschool teachers' and the child health care professional's (i.e. CHC psychologist) assessment in order to obtain an overall evaluation of the child's need for support in everyday life, and to detect children with ESSENCE symptoms early on. The goal being to facilitate positive development in the child by means of early promotion, prevention and intervention (37, 38, 55). Figure 1 illustrates the overall picture of the child's behavior based on the assessments of the parents, preschool teachers and the child psychologist.
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LillaLAPS correlated with the preschool's SDQ total and all SDQ subscales, except for emotional problems. indicating that the CHC psychologist's anamnesis with the parents includes the child's behavior both in preschool and at home. It is reasonable to assume that, in the conversation with the CHC psychologist, the parents convey the child's situation both in the home and the preschool context. After the assessment interview, the CHC psychologist also usually has access to the preschool's assessment of the child.
The majority of the children scored a need for further investigation due to ESSENCE symptoms, i.e. development related to age, everyday function, social interaction, emotional behavior and parents' anxiety, assessed using LillaLAPS. The domains in LillaLAPS appear to be similar to the SDQ with the supplement, scoring behavioural problems and everyday function, and the CEQ, scoring social interaction and engagement. High scores with LillaLAPS correlated with low function in everyday life in the home environment but not in preschool. Possible explanations are the structure in preschools and that the relationship between children and adults is not as close as between children and parents, plus preschool teachers are focused more on interaction with the group than with the individual child (33). The child adapts in preschool, which takes up a lot of energy, and then reacts in the home environment.
In a previous study, it emerged that CHC nurses, parents and the preschool doubted whether there was a reliable way to assess the mental health of preschool children (56). The present study shows that it is important to include different validated assessment forms, filled out by different informants, to gain as complete a picture as possible of the child's health.
Although the picture of the child's behavioural problems is consistent, there are differences between the parents' and the preschool teachers' assessment using SDQ total, SDQ subscales and SDQ supplement, which can be explained by the fact that the child is assessed in different contexts. Both parents and the preschool teachers see a strength in the child's social abilities. Parents, though, see challenges in especially behavioural problems and function in daily life, but also in hyperactivity, conduct and emotional problems. The preschool considers behavioural problems, hyperactivity, conduct problems, peer problems and problems in daily life as a greater challenge compared with the parents' assessment. Fälth et al. (56) showed poor coherence in SDQs filled in by parents and preschool teachers respectively. However, in line with the present study, the subscales hyperactivity, peer problems and prosocial scale correlated highly. The varying perceptions of the child's abilities can be explained by the fact that the child is in different contexts, in interaction with people with different demands and expectations. In addition, the parents' mental health, socioeconomic condition, other mother tongue and cultural contexts (57–59) may affect what the parents tell the CHC psychologist about their child's mental psychosocial health.
The results indicate that both preschool teachers and parents see symptoms that affect everyday function, even if preschool teachers screened lower than the parents. One explanation for the parents' appreciation of the problems in everyday life being higher compared to preschool teachers may be different roles, knowledge and experience of children's development. Preschool staff are trained in pedagogy, have more experience of children and can possibly normalize behaviours that parents perceive as problematic (56). In addition, preschool teachers consider the child more as part of the group, and see their task as supporting the group as a whole, while the parents see the individual child. In a recent dissertation, Gustafsson (29) showed that when preschool teachers used the SDQ they were able to notice and understand the child’s behaviour at an earlier stage. They also found it easier to communicate concerns to the parents; something which may potentially contribute to earlier detection and help for children who need special support.
The parents' and preschool teachers' assessment of the child using SDQ total and SDQ subscales, except for the prosocial behaviour scale, are consistent with a previous review that examined psychometric properties of the SDQ in children aged 4 to 12 (60). Croft et al. (61) also reported SDQ subscales to have high sensitivity in differentiating children with ESSENCE symptoms from the normal population of children in Sweden. However, the SDQ, like other psychometric instruments for assessing children, has its limitations.
A risk when assessing the preschool child is that preschool teachers pay more attention to hyperactive children who disturb the group, i.e. those with externalizing problems, than on internalized behavior (29, 62). Children with internalizing problems may worry preschool teachers, but they can more easily "handle" the child when it is quiet and inward-looking and does not disturb the group (47). Internalizing behaviour may also be difficult to identify among preschool children, due to insufficiently developed verbal and cognitive skills. Preschoolers instead use psychomotor skills to express internalization problems, such as clinging to adults (29). Taken together, there is a risk that children who do not show behavioural problems and hyperactivity, but have other mental illness (e.g. anxiety-related symptoms) will not receive help and support in time or be missed during preschool. Teachers also often miss these symptoms in school-age children (63). Ezpeleta et al. (55) pointed out that including ratings performed by parents enhanced detection of internalizing behaviour. We suggest that SDQ should be combined with CEQ and LillaLAPS for preschool children.
LillaLAPS is a new instrument for CHC psychologists assessing psychosocial health in preschool children (48, 54). LillaLAPS did not correlate with preschool teachers' assessment of SDQ emotional symptoms. Nevertheless, children whom the CHC psychologist assessed with LillaLAPS as having behavioural problems also had low scores for engagement (e.g. in play and social interaction) in preschool. This further illuminates the importance of not only paying attention to the active, externalizing child, but also the internalizing child who withdraws from peers and, for example, prefers to play by themselves. The negative correlations between LillaLAPS and preschool teachers' rating can be interpreted as an effect of the preschool environment.
In the present results the rating of engagement and social interaction according to the CEQ was lower than a normal population of children in Sweden (3.2 + 0.61) (29). This can be explained by the fact that the children in this study have been identified with ESSENCE symptoms, which can affect social interaction and engagement. Preschool teachers' assessment with the CEQ is in line with previous research that found that children with comorbid difficulties, such as hyperactivity and conduct problems, have lower engagement, less social interaction, and more peer problems that affect everyday functioning in the preschool context (29, 53, 64). Our conclusion is that the CEQ may be an alternative to detect children with internalizing behaviour as it focuses on engagement and interaction with peers and preschool teachers.
Even if the child is hyperactive, it seems that high engagement and social interaction help them to function well (29). However, children with low engagement and social interaction, alone or in combination with hyperactivity and conduct problems, continue to have problems, including decreasing engagement over time. Engagement improves the child's self-regulation (10), and facilitates both the child's learning (12) and well-being. Hence, it is important to use different screening instruments that assess different aspects of mental health to obtain a nuanced picture of the child. It is crucial to encourage high engagement and social interaction with peers and teachers, to enhance protective factors that generate positive spirals of good mental health (10, 65).
There are national guidelines for the use of validated psychometric instruments in the CHC psychologist assessment of children with behavioural problems, including ESSENCE symptoms. Various psychometric instruments are used in both primary child care and specialist care regarding children's development/behaviours. However, there are differences regarding the choice and application of instruments in clinical practice. There is also a lack of studies of sufficiently good quality and sufficient data (66). LillaLAPS is a promising alternative. However, LillaLAPS has only been used for children who are part of the PLUSS project within Jönköping County. It has to be further tested and validated in a Swedish population before implementation as a clinical assessment instrument. In addition, LillaLAPS should be supplemented with other assessments, such as SDQ and CEQ, as shown in the present study.
In order to detect children with behavioural problems earlier and counteract stigma (67), interprofessional collaboration is of great importance in the assessment of the child, including with the parents (29, 68). Another study (56) reported that preschool teachers want to identify children with problems to ensure the best interests of the child. A barrier, though, was that they felt uneasy about the parents' reactions and concerns about assessment, as well as fear of stigmatizing the child (69). Standardized instruments for assessment, instead of subjective opinions, could remove preschool teachers' fear of stigmatizing the child (29).
Early detection of ESSENCE symptoms promotes more effective intervention and reduces the risk of later mental illness and human suffering (70). The present results indicate that the SDQ is an effective tool for screening for behavioural problems and can therefore be used to identify children with psychiatric symptoms early in life. Early screening is in line with Skovgaard et al. (71), who found that predictors of neuro-developmental disorders and parent-child relationship disturbances could be identified in the first 10 months of life in children. There is also an economic benefit to early detection and thus the ability to prevent mental health problems in young children (72, 73). Therefore, CHCconcern for a toddler's behavior.