Finnish mothers’ and fathers’ reports of their boys and girls by using the Brief Infant-Toddler Social and Emotional Assessment (BITSEA)

Infant Behavior & Development 39 (2015) 136–147

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Infant Behavior and Development

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Finnish mothers’ and fathers’ reports of their boys and girls by using the Brief Infant-Toddler Social and Emotional Assessment (BITSEA) Jaana Alakortes a,∗ , Jenni Fyrstén a,b , Alice S. Carter c , Irma K. Moilanen a,b , Hanna E. Ebeling a,b a b c

Department of Child Psychiatry, Institute of Clinical Medicine, University of Oulu, Box 26, 90029 OYS, Oulu, Finland Clinic of Child Psychiatry, Oulu University Hospital, Oulu, Finland Department of Psychology, University of Massachusetts Boston, Boston, MA, United States

a r t i c l e

i n f o

Article history: Received 14 August 2014 Received in revised form 1 February 2015 Accepted 10 February 2015 Available online 28 March 2015 Keywords: BITSEA Infant Toddler Social–emotional Behavior problems Competence

a b s t r a c t This study investigated maternal and paternal reports about their very young boys and girls on the Brief Infant-Toddler Social and Emotional Assessment (BITSEA). Two samples were recruited through child health centers in Northern Finland. The infant sample consisted of 227 children (112 boys and 115 girls) (mean age 13.0 ± 1.1 months) and the toddler sample consisted of 208 children (94 boys and 114 girls) (mean age 19.3 ± 1.4 months). Among the infants, girls obtained higher paternal competence total scores than boys, whereas among the toddlers, both maternal and paternal competence total scores were higher for girls compared to boys. In the problem total scale, boys were scored higher than girls by mothers, but not by fathers, in both age groups. In the externalizing problem domain, maternal scores were higher for boys compared to girls among both samples, whereas paternal scores were significantly higher for boys than for girls only among the infants. Also maternal internalizing problem scores were higher for boys than for girls among the toddlers. Compared to fathers, mothers perceived more social–emotional competencies in toddler boys and girls, as well as more total, externalizing and dysregulation problems in toddler boys. However, significant differences between the maternal and paternal BITSEA ratings were not found among the infants of either sex. The results suggest that sex differences in the social–emotional/behavior domain may be observed by the parents among children as young as 11 to 24 months of age. Our findings highlight the importance of paying attention to probable sex differences when assessing and treating early social–emotional/behavior problems. © 2015 Elsevier Inc. All rights reserved.

1. Introduction During the last decades researchers and clinicians have become convinced that clinically significant social–emotional and behavioral (SEB) problems exist in early childhood, even among infants and toddlers younger than 3 years of age. These

Abbreviations: BITSEA, Brief Infant–Toddler Social and Emotional Assessment; CBCL, Child Behavior Checklist; ITSEA, Infant–Toddler Social and Emotional Assessment; SD, standard deviation; SEB, social–emotional and behavior. ∗ Corresponding author. Tel.: +358 40 5538306. E-mail address: [email protected] (J. Alakortes). http://dx.doi.org/10.1016/j.infbeh.2015.02.016 0163-6383/© 2015 Elsevier Inc. All rights reserved.

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observations have contributed to the creation of age appropriate, developmentally sensitive assessment tools and measures for systematic and broad evaluation of these problems (DelCarmen-Wiggins & Carter, 2001), such as The Brief Infant-Toddler Social and Emotional Assessment (BITSEA) (Briggs-Gowan, Carter, Irwin, Wachtel, & Cicchetti, 2004; Briggs-Gowan & Carter, 2006). Longitudinal studies have increased the body of evidence that a substantial proportion of early SEB problems are stable over time (Baillargeon, Keenan, & Cao, 2012; Briggs-Gowan, Carter, Bosson-Heenan, Guyer, & Horwitz, 2006; Lavigne et al., 1998; Mathiesen & Sanson, 2000; Mesman & Koot, 2001; Mäntymaa et al., 2012; Pihlakoski et al., 2006; Van Zeijl et al., 2006). For example, in a community sample of 1 to 3-year-old children (n = 1082) from the USA, approximately half of the children who had high parent-reported SEB problems continued to have such psychopathology one year later, even among the youngest, 1-year-old children (Briggs-Gowan et al., 2006). In a general population study from the Netherlands (n = 332), Mesman and Koot (2001) found that parent-reported internalizing and externalizing problems in 2 to 3-year-old children were predictive of their corresponding DSM-IV diagnoses (Shaffer, Fisher, & Lucas, 1998) 8 years later, even independent of the influence of early parent-reported adverse parenting characteristics (e.g., negative maternal attitude) and general family risk factors (e.g., family psychopathology and low socioeconomic status). The importance of early identification and interventions of SEB problems in infancy and toddlerhood has been highlighted also by associations with delayed social–emotional competence and disruptions in family life (Briggs-Gowan, Carter, Skuban, & Horwitz, 2001). Prevalence rates of parent-reported SEB problems in 2 to 3-year-old children have been found to range from approximately 5% to 24%, usually settling around 10% to 15% (Briggs-Gowan et al., 2001; Earls, 1980; Erol, Simsek, Oner, & Munir, 2005; Koot & Verhulst, 1991; Larson, Pless, & Miettinen, 1988; Lavigne et al., 1996; Sourander, 2001; Stallard, 1993). Studies reporting prevalence rates of mental health problems for children younger than 2 years are very scarce and vary in methods. In studies relying on parent-report measures, the prevalence rates of these problems have varied from approximately 4% to 14% (Baillargeon, Sward, Keenan, & Cao, 2011; Bayer, Hiscock, Ukoumunne, Price, & Wake, 2008; Briggs-Gowan et al., 2001; Mathiesen & Sanson, 2000). For example, Mathiesen and Sanson (2000) examined early behavior problems in a population based sample of 18-month-old Norwegian children (n = 750) and found prevalence rates ranging from approximately 6% to 14% for 4 dimensions of maladjustment (social adjustment, emotional adjustment, overactive-inattentive and regulation) by applying the Behavior Checklist (BCL) (Richman & Graham, 1971). In Denmark, Skovgaard et al. (2007) investigated a random sample of 1.5-year-old children (n = 211) from the Copenhagen Child Cohort 2000 and diagnosed mental health problems in 16–18% of these toddlers. Compared to the large body of evidence regarding older children’s SEB problems (e.g., Rescorla et al., 2007), parallel trends of significant sex differences have been found in some studies among 2 to 3-year-olds (Erol et al., 2005; Koot & Verhulst, 1991; Lavigne et al., 1996; Sourander, 2001; Stallard, 1993). According to these toddler studies, overall mental health problems and/or externalizing problems have been more common in boys than in girls, whereas internalizing and/or dysregulation problems may be more common in girls than in boys. Among children younger than 2 years, significant sex differences in the prevalence rates of SEB problems have not usually been found (e.g., Baillargeon et al., 2011; Briggs-Gowan et al., 2001; Skovgaard et al., 2007). However, Carter, Briggs-Gowan, Jones, and Little (2003) reported significant sex differences in parental ratings on the Infant-Toddler Social and Emotional Assessment (ITSEA) for a representative birth cohort sample of 12 to 36-month-old children (n = 1235) from the USA; boys were rated higher than girls in activity/impulsivity, whereas girls were rated higher than boys on anxiety and most competence scales. There are few studies addressing paternal reports about their infant/toddler-age children’s SEB problems. In their metaanalysis, Achenbach, McConaughy, and Howell (1987) found a moderate correlation between mothers’ and fathers’ ratings of their 1.5 to 19-year-old children’s emotional/behavior problems (mean r = 0.59), with no significant difference between the mean correlations for overcontrolled (mean r = 0.59) and undercontrolled (mean r = 0.62) problems. However, results of a more recent meta-analysis suggested that the correspondence (effect sizes) between maternal and paternal ratings was moderate for internalizing and high for externalizing and total behavior problems among 3 to 19-year-old children (Duhig, Renk, Epstein, & Phares, 2000). According to this later meta-analysis, interparental agreement was also higher for adolescents than for children in early (3–5-year-olds) and middle (6–12-year-olds) childhood (Duhig et al., 2000). Concerning 1 to 3-yearold children, moderate to high interparental agreement was reported for the ITSEA with intraclass correlation coefficient (ICC) ranging from 0.43 to 0.79 for scales and domains (Carter et al., 2003). Correspondingly, for the BITSEA ICC ranged from 0.70 for boys to 0.78 for girls for the problem total score and from 0.58 for girls to 0.67 for boys for the competence total score (Briggs-Gowan & Carter, 2006). In terms of discrepancy, mothers tended to report slightly more behavior problems about their offspring (aged 3–19 years) than fathers (Duhig et al., 2000). Some later studies have reported similar findings (Luoma, Koivisto, & Tamminen, 2004b; Van der Valk, van den Oord, Verhulst, & Boomsma, 2001), particularly concerning boys (Luoma et al., 2004b). Parental reports generally play an invaluable role in young children’s mental health assessments, because many challenges exist concerning these assessments compared to older children and adults. For example, young children have very limited verbal and cognitive abilities to express their thoughts and feelings (Carter, Godoy, Marakovitz, & Briggs-Gowan, 2009). In addition, young child’s behavior during a short office visit in an unfamiliar setting may not be representative of behavior in day-to-day settings (Briggs-Gowan et al., 2004), and professionals miss a substantial number of serious cases with early SEB problems (Klein Velderman, Crone, Wiefferink, & Reijneveld, 2010). Parental worry has been shown to play a central role in help-seeking for children with behavior problems (Ellingson, Briggs-Gowan, Carter, & Horwitz, 2004). However, many parents have insufficient developmental knowledge to distinguish between normative misbehaviors and clinically

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concerning SEB problems in young children (Ellingson et al., 2004). For example, parents’ educational or occupational level does not necessarily increase parental perception of children’s problem behaviors and utilization of child mental health services (Verhulst & van der Ende, 1997). In turn, parental psychopathology may lower a parent’s threshold for assessing his/her child’s behavior as problematic (Verhulst & van der Ende, 1997), but even if the parent’s evaluation was not consistent with the child’s actual behavior (Müller, Achtergarde, & Furniss, 2011), parental early negative expectations and perceptions may set the child at elevated risk for future SEB problems (Mesman & Koot, 2001; Luoma et al., 2004a). Consequently, utilization of standardized, norm-referenced parent-report screening questionnaires may improve early identification of mental health problems among young children, and do so in a time-efficient and cost-effective way (Briggs-Gowan et al., 2004). The BITSEA is a screening tool that was developed for identifying possible SEB problems and/or delays or deficits in social–emotional competence in children ages 12 to 35 months (Briggs-Gowan et al., 2004; Briggs-Gowan & Carter, 2006). (For brevity, “deficits” will be used to refer to “delays and deficits”). The BITSEA was derived from a longer and more comprehensive questionnaire, the ITSEA (Carter & Briggs-Gowan, 2006), especially for use in settings requiring a more timeefficient and concise screening tool. The BITSEA may be used e.g., as a part of routine examinations at preventive child-health visits (Kruizinga, Jansen, Mieloo, Carter, & Raat, 2013) or in early intervention settings (Briggs-Gowan & Carter, 2007), and most parents are capable of completing it independently in a few minutes (Briggs-Gowan & Carter, 2006). The BITSEA has some special strengths. It is brief and easy to administer, score and interpret (Briggs-Gowan & Carter, 2006). Besides behavioral problems, the BITSEA addresses deficits in acquisition of social–emotional competencies and behaviors that may be indicative of autism spectrum disorders. The BITSEA has evidenced acceptable psychometric properties (e.g., internal consistency, test–retest and inter-rater reliability, one-year stability, concurrent validity relative to the Child Behavior Checklist (CBCL)/1.5–5 (Achenbach & Rescorla, 2000) scores and evaluator ratings) (Briggs-Gowan et al., 2004; Briggs-Gowan & Carter, 2006). Results of a recent study from the USA concerning clinical validity of the BITSEA indicated that the BITSEA problem index has fair to excellent sensitivity and specificity relative to diagnosis by “gold standard” interview and clinical-range CBCL scores (Briggs-Gowan et al., 2013). The BITSEA has also demonstrated excellent sensitivity and good specificity in detecting autistic disorder (Briggs-Gowan & Carter, 2006). Finally, in a large birth cohort sample (n = 1004 children) from the USA, the BITSEA screen status at 12 to 36 months of age was found to predict parent- and teacher-reported psychiatric problems and disorders at early elementary school age (Briggs-Gowan & Carter, 2008). Recent studies have supported the reliability and validity of the BITSEA as a screening measure of young children’s SEB problems also in Turkey (Karabekiroglu et al., 2009; Karabekiroglu, Briggs-Gowan, Carter, Rodopman-Arman, & Akbas, 2010) and in the Netherlands (Kruizinga et al., 2012). In a Finnish pilot study concerning 18-month-old children (n = 50), the BITSEA problem index had good internal consistency, and correlations between the BITSEA problem total and CBCL/1.5–5 internalizing, externalizing and total problem scores were evident (Haapsamo et al., 2009). When significant sex differences have been found in the earlier BITSEA studies, girls have been rated higher than boys in competence scores, whereas problem total scores have been higher for boys than for girls (Briggs-Gowan et al., 2004; Briggs-Gowan & Carter, 2006; Karabekiroglu et al., 2009, 2013; Kruizinga et al., 2012, 2013). To our knowledge, only Turkish researchers have evaluated possible differences between the maternal and paternal BITSEA ratings so far, and they found no significant differences between the maternal and paternal scores in any age or sex groups (Karabekiroglu et al., 2009). As described above, there are only few studies focusing on possible sex differences in the occurrence and appearance of SEB problems among children younger than 2 years of age and comparing mothers’ and fathers’ reports about their young children’s SEB problems and competencies. The main purpose of the current study was to compare boys’ and girls’ BITSEA problem and competence scores among 12-month-old infants and 18-month-old toddlers recruited through public child health centers in the city of Oulu, Finland. The second aim was to investigate probable differences in parents’ perceptions of their young children’s SEB problems and skills related to parental and child sex. 2. Methods 2.1. Setting The study was carried out in Oulu which is the capital of northern Finland, in Scandinavia. Between 2006 and 2011 the population of Oulu increased from 129 000 to 142 000 and the birth rate was about 2000 live born children per annum (www.ouka.fi/Statistical Yearbook of the City of Oulu, 2011). The Finnish public child health center organization covers all municipalities in Finland and it is free of charge for families. Almost all children in Oulu attend regular well-child visits at child health centers during their first six years of life, before the school age. Thus, the data collection was carried out in collaboration with nurses at all child health centers of Oulu. 2.2. Procedure The BITSEA data collection was a part of a research project concerning early identification of young children’s mental health problems in Northern Finland launched in 2008. The current paper is the first publication regarding the project results. The research was approved by the Ethical Committee of the University Hospital of Oulu and the Municipal Boards of the Social and Health Care Units of the City of Oulu. The active BITSEA data collection took place from February 2008 to March 2009

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for 18-month-old toddlers and from February 2010 to February 2011 for 12-month-old infants. After training, health care nurses delivered the BITSEA (a red copy to mothers and a blue copy to fathers) and background information questionnaires to parents during routine well-child visits. Parents mailed completed questionnaires and a written informed consent form to researchers in a pre-paid envelope. Parents could also leave their informed consent form with contact information with the nurse; in these cases, when questionnaires were not returned, researchers telephoned parents and remailed materials to encourage participation. The BITSEA data was used only for research purposes and nurses were not aware of the children’s BITSEA scores during the well-child visits. Participation for both nurses and parents was completely voluntary. 2.3. Participants In 2010–2011 the target population was all 12-month-old children and their parents who participated in the child’s well-child visit in the city of Oulu. Unfortunately, it was not possible to get reliable information about the actual number of parents who were invited in the study by nurses. However, given the facts that almost all children in Oulu attend these well-child visits and the data collection was performed during about one year, the number of 1-year-old population in Oulu at the end of the year 2010 (n = 1964) was used as an estimated number of the target population. Similarly, in 2008–2009 the target population was all 18-month-old children and their parents who participated in the child’s well-child visit in Oulu, and the number of 1-year-old population in Oulu at the end of the year 2008 (n = 1757) was used as an estimation of the target population. The numbers of the 1-year-olds were obtained from the Statistics Finland (www.stat.fi). An initial infant sample consisted of 230 children and toddler sample consisted of 209 children. Thus, both samples represented ∼10% of the estimated target populations. Three subjects were excluded from the initial infant sample due to out of range ages (two adjusted ages were under 11 months and one child was over 18 months). One child who was over 24 months was excluded from the initial toddler sample. Thus, the final infant sample consisted of 227 children, 112 boys (49.3%) and 115 girls (50.7%), with a mean age of 13.0 months. The final toddler sample consisted of 208 children, 94 boys (45.2%) and 114 girls (54.8%), with a mean age of 19.3 months. The maternal BITSEA data was available for all children in both samples. The paternal BITSEA data was available for 205 of 227 (90.3%) infants, 104 of 112 (92.9%) boys and 101 of 115 (87.8%) girls, and for 181 of 208 (87.0%) toddlers, 82 of 94 (87.2%) boys and 99 of 114 (86.8%) girls. Among the final samples, child age was adjusted for 4 infants (2 boys and 2 girls) and 5 toddlers (3 boys and 2 girls) born at 36 weeks or less gestation. None of the children had diagnoses of severe primary diseases or developmental delays. Every child whose Apgar score status was available to the researchers had the last given Apgar score ≥6. More detailed information concerning child age, weight at birth, Apgar scores, as well as parental age and educational level is shown in Table 1. There were no significant differences between the infant sample boys and girls, or between the toddler sample boys and girls, concerning child age, parental age and educational level. Moreover, no significant differences were found between the infant and toddler boys, or between the infant and toddler girls, in relation to weight at birth, parental age and educational level. Based on the background information data, no significant differences were found between the infants with and without the paternal BITSEA data concerning child sex and age, or parental age and educational level. Significant differences were neither found between the toddlers with and without the paternal BITSEA data concerning child sex, age and weight at birth, or parental age and maternal educational level. However, the infant girls with the paternal BITSEA data were somewhat lighter at birth than the infant girls without the paternal BITSEA data (p = 0.001), and the fathers of toddler girls with the paternal BITSEA data were somewhat higher educated than the fathers of toddler girls without the paternal BITSEA data (p = 0.015). Although both samples represented only ∼10% of the target populations (18-month-old inhabitants of Oulu in 2008–2009 and 12-month-old inhabitants of Oulu in 2010–2011), no significant differences were found between the final study samples and the corresponding target populations in relation to the two available child characteristics: (1) children’s mean weight at birth and (2) mothers’ mean age at the child’s birth, except for the infant sample boys who were on average slightly heavier at birth than the target population boys born in 2009 or 2010 (p = 0.032 or 0.027, respectively, but the average effect size was small, d = 0.209). Background characteristics of the target populations were obtained from the Medical Birth Register at The National Institute for Health and Welfare (THL). Additionally, there were no significant differences between the educational levels of the mothers in the study samples and the target females, or between the educational levels of the fathers of the toddler girls and the target males, based on data on the target populations (30–34-year-old citizens of Oulu in 2008–2009 or 2010–2011), by applying the Statistics Finland (www.stat.fi). However, fathers of infant boys and girls, and of toddler boys, were somewhat higher educated than the target males (with p-values of 0.019–0.029, 0.003–0.010, and 0.045–0.048, respectively). The corresponding average effect sizes were at the medium level (w = 0.262, 0.309, and 0.267, respectively). Finally, 2.7% (12/446) of the infant sample parents and 2.1% (8/390) of the toddler sample parents were immigrants, which corresponded percentages of the non-native population in Oulu in the data collection years (www.ouka.fi/ Statistical Yearbook of the City of Oulu 2008–2011). 2.4. Measures 2.4.1. The BITSEA The BITSEA questionnaire (Briggs-Gowan & Carter, 2006) consists of 42 items; 31 items concern SEB problems and 11 items concern deficits in social–emotional competence. The problem items address problematic behavior in externalizing

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Table 1 Background characteristics of the study samples. Child variables

Infant boys (n = 112) Mean (SD; range)

Infant girls (n = 115) Mean (SD; range)

Infant total (n = 227) Mean (SD; range)

Toddler boys (n = 94) Mean (SD; range)

Toddler girls (n = 114) Mean (SD; range)

Toddler total (n = 208) Mean (SD; range)

Age when BITSEA completed (months)

12.9 (1.1; 11.5–17.6) 3655 (520; 2150–5200) 1 n (%) 106 (94.6)

13.0 (1.2; 11.2–17.9) 3476 (488; 2100–4490) 0 n (%) 111 (96.5)

13.0 (1.1; 11.2–17.9) 3564 (511; 2100–5200) 1 n (%) 217 (95.6)

19.2 (1.3; 16.4–24.0) 3657 (515; 2185–5220) 1 n (%) 85 (90.4)

19.4 (1.4; 16.5–23.7) 3462 (482; 2160–4615) 0 n (%) 103 (90.4)

19.3 (1.4; 16.4–24.0) 3550 (505; 2160–5220) 1 n (%) 188 (90.4)

Parent variables

Infant boys (n = 112) Mean (SD; range)

Infant girls (n = 115) Mean (SD; range)

Infant total (n = 227) Mean (SD; range)

Toddler boys (n = 94) Mean (SD; range)

Toddler girls (n = 114) Mean (SD; range)

Toddler total (n = 208) Mean (SD; range)

Mother’s age at the child’s birth (years)

29.4 (5.7; 17–41) 0 31.4 (6.5; 19–47) 0 n (%) 4 (3.6) 45 (40.2) 63 (56.3) 0 (0) n (%) 4 (3.6) 56 (50.0) 50 (44.6) 2 (1.8)

29.0 (4.6; 17–40) 1 30.9 (5.6; 17–48) 1 n (%) 5 (4.3) 33 (28.7) 77 (67.0) 0 (0) n (%) 4 (3.5) 42 (36.5) 65 (56.5) 4 (3.5)

29.2 (5.2; 17–41) 1 31.2 (6.0; 17–48) 1 n (%) 9 (4.0) 78 (34.4) 140 (61.7) 0 (0) n (%) 8 (3.5) 98 (43.2) 115 (50.7) 6 (2.6)

29.0 (5.1; 20–42) 1 30.9 (6.3; 19–49) 4 n (%) 5 (5.3) 31 (33.0) 47 (50.0) 11 (11.7) n (%) 2 (2.1) 42 (44.7) 43 (45.7) 7 (7.4)

29.8 (5.5; 17–43) 1 31.4 (6.2; 21–47) 2 n (%) 7 (6.1) 31 (27.2) 68 (59.6) 8 (7.0) n (%) 5 (4.4) 43 (37.7) 56 (49.1) 10 (8.8)

29.4 (5.3; 17–43) 2 31.1 (6.2; 19–49) 6 n (%) 12 (5.8) 62 (29.8) 115 (55.3) 19 (9.1) n (%) 7 (3.4) 85 (40.9) 99 (47.6) 17 (8.2)

Weight at birth (g) - Missing data (n) Last given Apgar score (≥6)a

- Missing data (n) Father’s age at the child’s birth (years) - Missing data (n) Mother’s educational level (a) Elementary school (b) Vocational/senior high school (c) College/university (d) Undefined Father’s educational level (a) Elementary school (b) Vocational/senior high school (c) College/university (d) Undefined

Note: SD = standard deviation. a Every child whose Apgar score status was available to the researchers had the last given Apgar score ≥6.

(6 items; e.g., impulsivity, defiance, peer aggression), internalizing (8 items; e.g., fearfulness, worry, anxiety, sadness) and dysregulation (8 items; e.g., sleep and eating problems, negative emotionality, sensory sensitivities) domains, as well as rare behaviors that may be early markers of autism spectrum disorders (e.g., repeating of same action or phrase over and over without enjoyment) or other significant psychopathology (14 red flag items; e.g., hurts self on purpose). Some of the items address problematic behavior overlapping in two or three domains (e.g., avoids physical contact). Besides 9 problem items, the autism domain consists of 8 competence items (deficits in those). The competence items rate the child’s skills of attention, compliance, mastery motivation, prosocial peer relations, empathy, imitation/play, and social relatedness. Response alternatives for the BITSEA items are Not true/rarely (=0), Somewhat true/sometimes (=1), and Very true/often (=2), providing problem total score (range 0–62) and competence total score (range 0–22). High problem total score and/or low competence total score indicates that the assessed child may have SEB problems and/or deficits in competence, and follow-up or more comprehensive evaluation is needed to determine whether or not difficulties are clinically significant. The BITSEA cut score values are based on a national USA standardization sample for 12 to 36-month-olds (by sex and age in 6-month age bands) and set at the highest 25th percentile for problem total scores and at the lowest 15th percentile for competence total scores. In addition, the BITSEA form includes two questions addressing the parental level of worry about the child’s (1) psychosocial and (2) language development but not counting toward the BITSEA scores. The current study utilized the Finnish translation of the BITSEA developed for a previous Finnish BITSEA pilot study (Haapsamo et al., 2009). Because there are no standardized Finnish cut score values for the BITSEA, the USA standardized cut scores (Briggs-Gowan & Carter, 2006) were applied; for 12–17-month-olds competence total score ≤12 (for both sexes) and problem total score ≥13 (for both sexes), and for 18–23-month-olds competence total score ≤14 (for both sexes) and problem total score ≥15 (for boys) or ≥13 (for girls). If the child’s competence total score was at or below the competence cut score, it was in the possible deficit range. Correspondingly, if the child’s problem total score was at or above the problem cut score, it was in the possible problem range. All the infants, and the toddler sample subjects who were slightly under 18 months of age (11 boys and 11 girls rated by mothers, 11 boys and 9 girls rated by fathers), were screened by using the cut score values for 12–17-month-old children. The toddlers who were at minimum 18-month-olds were screened by using the cut score values for 18–23-month-old children. Consistent with scoring guidelines, child age was adjusted for children born at 36 weeks or less gestation. If ≥2 competence and/or ≥5 problem items per a rater were unanswered, the corresponding total score/-s could not be calculated and used in the analyses. Only the infants and toddlers whose both competence and problem total

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Table 2 Maternal and paternal mean scores and standard deviations of the BITSEA scales and domains for the infant and toddler sample boys and girls. Infant sample

Maternal

Paternal

(n mat/n pat/n both)

Mean (SD)

Mean (SD)

Total (224/198/197) Boys (110/100/99) Girls (114/98/98) pa /Effect size (d)c Total (223/200/198) Boys (109/103/101) Girls (114/97/97) pa /Effect size (d)c Total (224/202/201) Boys (111/103/103) Girls (113/99/98) pa /Effect size (d)c Total (223/203/200) Boys (109/104/102) Girls (114/99/98) pa /Effect size (d)c Total (225/202/202) Boys (111/103/103) Girls (114/99/99) pa /Effect size (d)c

Competence 15.30 (2.79) 14.95 (2.75) 15.64 (2.79) 0.062/– Problem total 8.15 (4.13) 8.63 (4.27) 7.69 (3.96) 0.046* /0.228 Externalizing 1.91 (1.58) 2.26 (1.65) 1.57 (1.43) 0.001* /0.447 Internalizing 1.17 (1.14) 1.17 (1.08) 1.18 (1.20) 0.767/– Dysregulation 3.10 (2.05) 3.04 (1.90) 3.16 (2.20) 0.657/–

pb /Effect size (d)c

Toddler sample

Maternal

Paternal

(n mat/n pat/n both)

Mean (SD)

Mean (SD)

15.07 (3.05) 14.58 (3.10) 15.57 (2.94) 0.022* /0.328

0.525/– 0.383/– 0.975/–

Total (207/181/180) Boys (93/82/81) Girls (114/99/99) pa /Effect size (d)c

7.67 (4.51) 7.95 (4.56) 7.36 (4.46) 0.313/–

0.277/– 0.252/– 0.701/–

Total (207/181/180) Boys (93/82/81) Girls (114/99/99) pa /Effect size (d)c

1.81 (1.56) 2.08 (1.67) 1.53 (1.39) 0.011* /0.358

0.737/– 0.388/– 0.595/–

Total (207/181/180) Boys (93/82/81) Girls (114/99/99) pa /Effect size (d)c

0.93 (1.07) 0.93 (1.18) 0.93 (0.96) 0.653/–

0.024* /0.157 0.173/– 0.071/–

Total (208/181/181) Boys (94/82/82) Girls (114/99/99) pa /Effect size (d)c

2.85 (2.10) 2.73 (1.97) 2.97 (2.24) 0.416/–

0.140/– 0.125/– 0.506/–

Total (207/181/180) Boys (93/82/81) Girls (114/99/99) pa /Effect size (d)c

Competence 18.02 (2.36) 17.28 (2.52) 18.63 (2.04) <0.001* /0.589 Problem total 7.49 (4.65) 8.68 (5.16) 6.53 (3.97) 0,001* /0.467 Externalizing 1.95 (1.71) 2.55 (1.93) 1.46 (1.32) <0.001* /0.659 Internalizing 1.02 (1.20) 1.22 (1.26) 0.86 (1.12) 0.020* /0.302 Dysregulation 2.74 (2.08) 3.03 (2.39) 2.51 (1.77) 0.081/–

pb /Effect size (d)c

17.28 (2.81) 16.61 (2.73) 17.84 (2.77) 0.002* /0.447

0.001*/0.259 0.006*/0.315 0.032*/0.220

6.22 (3.81) 6.33 (4.04) 6.13 (3.62) 0.729/–

0.005* /0.210 <0.001* /0.408 0.919/–

1.46 (1.38) 1.66 (1.39) 1.30 (1.36) 0.056/–

0.001* /0.264 <0.001* /0.453 0.460/–

0.87 (1.08) 1.04 (1.29) 0.74 (0.85) 0.063/–

0.825/– 0.560/– 0.603/–

2.16 (1.72) 2.06 (1.79) 2.24 (1.66) 0.269/–

0.001* /0.258 <0.001* /0.419 0.321/–

Note: n mat = number of subjects with maternal scores; n pat = number of subjects with paternal scores. Only the subjects who were rated each by both of their parents (n both) were included in the analyses comparing maternal and paternal scores. Significance of the difference between the scores of boys and girls (pa ) was calculated by Mann–Whitney U or t-test (depending on the normality of the score distributions) for two independent samples. Significance of the difference between the maternal and paternal scores (pb ) was calculated by paired samples t-test. * Significant difference (p < 0.05) between the scores. Effect size (d)c was calculated for the difference between the two means, if the difference between the corresponding scores was statistically significant (p < 0.05). As defined by Cohen (1988), effect sizes (d) of ∼0.20 are small, ∼0.50 are medium, and ∼0.80 are large.

scores could be calculated were included in the analyses concerning the BITSEA screen status. Concerning the externalizing, internalizing and dysregulation problem domains, if ≥2 items per a domain were unanswered, the corresponding domain score was not calculated and included in the further analyses. The exact numbers of the scores included in the analyses (after exclusions due to missing values) are presented in Tables 2 and 3.

2.4.2. Background information questionnaire Information about basic background characteristics of the samples, e.g., child weight at birth, Apgar scores, parental age and educational level, was inquired via a single parent-report questionnaire planned by the authors.

2.5. Data analyses Differences concerning the background characteristics were examined with t-tests (2-tailed), Pearson chi-square and Fisher’s exact tests (2-sided). Cronbach’s alpha was used to assess internal consistency of the maternal and paternal BITSEA competence and problem total scale scores, as well as item clusters for externalizing, internalizing and dysregulation problem scores. Alphas of ≥0.70 were considered adequate, alphas of 0.60–0.70 were marginal, and alphas of <0.60 were low. Depending on normality of the score distributions, significance of the differences between the BITSEA scores of boys and girls were tested with Mann–Whitney U or t-test for two independent samples. Based on the normality (by graphic evaluation) of the score subtraction distributions, differences between the maternal and paternal scores were examined by paired samples t-test. Effect sizes were calculated by using G*Power 3.1.9.2 program (Faul, Erdfelder, Lang, & Buchner, 2007). As defined by Cohen (1988), an effect size for the difference between two means can be described as small (d ∼ 0.20), medium (d ∼ 0.50), or large (d ∼ 0.80). Correspondingly, an effect size for the difference between proportions can be defined as small (w ∼ 0.10), medium (w ∼ 0.30), or large (w ∼ 0.50) (Cohen, 1988). Interactions across the scores by child and parental sex were tested with repeated measures ANOVA. Cross-tabulation, Pearson chi-square test and Fisher’s exact test were used for calculating and analyzing the percentages of the study subjects who were screened to be in the possible deficit and/or problem ranges by the BITSEA total scores. All analyses were performed with SPSS version 22.0 for Windows. p Values <0.05 were considered statistically significant.

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Table 3 Maternal and paternal proportions of the infant and toddler sample boys and girls in the possible deficit and/or problem ranges by the BITSEA total scores. Infant sample

Maternal

Paternal

Toddler sample

Maternal

Paternal

(n mat/n pat)

n (%)

n (%)

pb

(n mat/n pat)

n (%)

n (%)

pb

42 (21.4) 26 (26.0) 16 (16.7) 0.111

0.081 0.100 0.475

Total (207/181) Boys (93/82) Girls (114/99) pa

27 (14.9) 17 (20.7) 10 (10.1) 0.046*

0.015* 0.109 0.053

25 (12.8) 13 (13.0) 12 (12.5) 0.916

0.925 0.359 0.380

Total (207/181) Boys (93/82) Girls (114/99) pa

11 (6.1) 6 (7.3) 5 (5.1) 0.549

0.080 0.108 0.403

61 (31.1) 35 (35.0) 26 (27.1) 0.231

0.259 0.693 0.238

Total (207/181) Boys (93/82) Girls (114/99) pa

36 (19.9) 21 (25.6) 15 (15.2) 0.079

0.310 0.522 0.419

Total (222/196) Boys (108/100) Girls (114/96) pa Total (222/196) Boys (108/100) Girls (114/96) pa Total (222/196) Boys (108/100) Girls (114/96) pa

Deficits 33 (14.9) 18 (16.7) 15 (13.2) 0.463 Problems 29 (13.1) 19 (17.6) 10 (8.8) 0.051 Deficits and/or problems 58 (26.1) 35 (32.4) 23 (20.2) 0.038*

Deficits 15 (7.2) 11(11.8) 4 (3.5) 0.022* Problems 23 (11.1) 14 (15.1) 9 (7.9) 0.103 Deficits and/or problems 33 (15.9) 20 (21.5) 13 (11.4) 0.048*

Note: Maternal and paternal proportions of the infant and toddler sample subjects (total, and separately boys and girls) whose competence total scores were in the possible deficit/delay range (at or below the cut score by age and sex; = Deficits), whose problem total scores were in the possible problem range (at or above the cut score by age and sex; = Problems), and whose competence and/or problem total scores were in the combined possible deficit/delay and/or problem range (=Deficits and/or Problems). n mat = number of subjects with maternal scores; n pat = Number of subjects with paternal scores. Only the subjects whose both competence and problem total scores (maternal and/or paternal) could be calculated were included in the analyses. Significance of the difference between the percentages of boys and girls (pa ) and between the maternal and paternal percentages (pb ) was calculated by Pearson chi-square or Fisher’s exact test. * Significant difference (p < 0.05) between the percentages.

3. Results 3.1. Comparison of boys’ and girls’ scores 3.1.1. Infant sample Among the sample of infants (n = 227), only paternal competence total scores were significantly higher for girls than for boys and only maternal problem total scores were significantly higher for boys than for girls (Table 2). For a further examination, maternal and paternal scores were calculated also for externalizing, internalizing, and dysregulation problem domains. In the externalizing problem domain, both maternal and paternal scores were significantly higher for boys than for girls and also the effect sizes for these differences were closer to the medium than small level. There were no significant differences between the scores by child sex in the internalizing and dysregulation problem domains. 3.1.2. Toddler sample Among the sample of toddlers (n = 208), both maternal and paternal competence total scores were significantly higher for girls than for boys and the corresponding effect sizes were at the medium level (Table 2). In the problem total scale, only maternal scores were significantly higher for boys than for girls and the corresponding effect size was at the medium level. In the externalizing problem domain, maternal scores were significantly higher for boys than for girls and the effect size for the difference was even closer to the large than medium level, whereas the difference between the corresponding paternal scores approached statistical significance. In the internalizing problem domain, only maternal scores were significantly higher for boys than for girls. There were no significant differences between the scores by child sex in the dysregulation problem domain. 3.2. Comparison of maternal and paternal scores 3.2.1. Infant sample For a comparison of maternal and paternal scores, only the infants (n = 202) who were assessed each by both of their parents were included in the analyses (Table 2). There were no significant differences between the maternal and paternal scores by child sex in any scale or domain. However, in the internalizing domain, maternal scores were significantly higher than paternal scores for the total group of infants (boys and girls analyzed together). There were no significant interactions across the scores by child and parental sex in any scale or domain. 3.2.2. Toddler sample Among the toddlers (n = 181) who were assessed each by both of their parents, maternal scores were significantly higher than paternal scores for both boys and girls in the competence total scale (Table 2). Maternal scores were significantly higher compared to paternal scores for boys and for the total group also in the problem total scale, and in the externalizing and

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dysregulation problem domains. Furthermore, the effect sizes for the differences between the maternal and paternal scores for boys in the problem total scale, as well as in the externalizing and dysregulation problem domains, reached the medium level. Statistically significant interactions across the scores by child and parental sex were found in the problem total scale (p = 0.002), and in the externalizing (p = 0.004) and dysregulation (p = 0.009) problem domains. 3.3. Internal consistency of maternal and paternal scores 3.3.1. Infant sample Internal consistencies (Cronbach’s ˛) of the maternal and paternal BITSEA scores were 0.61 and 0.64 for the competence total scale, and 0.66 and 0.72 for the problem total scale. Alphas for the maternal and paternal BITSEA scores were 0.55 and 0.57 for the externalizing, 0.34 and 0.39 for the internalizing, and 0.54 and 0.59 for the dysregulation problem domains. 3.3.2. Toddler sample Internal consistencies of the maternal and paternal BITSEA scores were 0.61 and 0.69 for the competence total scale, and 0.75 and 0.63 for the problem total scale. Alphas for the maternal and paternal BITSEA scores were 0.59 and 0.52 for the externalizing, 0.42 and 0.39 for the internalizing, and 0.60 and 0.41 for the dysregulation problem domains. 3.4. Proportions of study subjects in the possible deficit and/or problem ranges Table 3 shows the percentages of the infant and toddler sample subjects whose (1) competence total scores were in the possible deficit range (at or below the cut score), (2) problem total scores were in the possible problem range (at or above the cut score), and (3) competence and/or problem total scores were in the combined possible deficit and/or problem range, according to the cut score values by age and sex (Briggs-Gowan & Carter, 2006). 3.4.1. Infant sample Neither maternal nor paternal percentages of boys in the possible deficit range were significantly higher than the corresponding percentages of girls. However, the maternal percentage of boys in the possible problem range was twice as high as the corresponding percentage of girls, and the difference approached also statistical significance. Furthermore, the maternal, but not paternal, percentage of boys was significantly higher than the percentage of girls in the combined possible deficit and/or problem range. No significant differences were found between the maternal and paternal percentages of these infants in any of the ranges. Only four infant participants (1.8%), two boys (1.9%) and two girls (1.8%), according to maternal ratings and six infant participants (3.1%), four boys (4.0%) and two girls (2.1%), according to paternal ratings were screened to have both possible SEB problems and deficits in competence. 3.4.2. Toddler sample Both maternal and paternal percentages of boys in the possible deficit range were significantly higher than the corresponding percentages of girls. However, neither maternal nor paternal percentages of boys in the possible problem range were significantly higher than the corresponding percentages of girls. Only the maternal percentage of boys in the combined possible deficit and/or problem range was significantly higher than the corresponding percentage of girls. When comparing maternal and paternal ratings, fathers perceived significantly more possible deficits in competence among all the toddlers compared to mothers, and the corresponding difference approached significance also among girls. There were no significant differences between the maternal and paternal percentages of these toddlers in other of the ranges. Five toddler sample boys (2.4% of all children and 5.4% of boys) and no girls according to maternal ratings, and two toddler sample boys (1.1% of all children and 2.4% of boys) and no girls according to paternal ratings were screened to have both possible SEB problems and deficits in competence. 4. Discussion In the current study, when comparing boys’ and girls’ scores, infant girls obtained higher competence total scores than boys by paternal ratings, and infant boys obtained higher problem total scores than girls by maternal ratings. In the externalizing problem domain, both maternal and paternal scores were higher for infant boys than for girls and also the effect sizes for the differences reached the medium level. Among the toddlers, girls obtained higher competence total scores than boys by both parents’ ratings, and boys obtained higher maternal problem total scores than girls. Also all of the corresponding effect sizes were at the medium level. In the externalizing problem domain, toddler boys scored significantly higher than girls by maternal ratings and the effect size for the difference was large, whereas the corresponding difference in paternal ratings approached significance. Also maternal internalizing problem scores were higher for toddler boys than for girls. Our toddler sample findings and paternal ratings for the infants are consistent with the BITSEA study results from the USA (mostly maternal ratings) which indicated that competence total scores were significantly higher for girls than for

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boys in each BITSEA age group (Briggs-Gowan & Carter, 2006). In both age groups, we found significantly higher maternal problem total scores for boys than for girls, while in the USA only a parallel trend-level sex effect was found (Briggs-Gowan & Carter, 2006). In line with our toddler sample findings, other large samples of 2-year-olds from the Netherlands (mostly rated by mothers) also found significantly higher BITSEA competence total scores for girls than for boys, and significantly higher problem total scores for boys than for girls (Kruizinga et al., 2012, 2013). In contrast, significant sex differences were not reported among maternal or paternal BITSEA ratings of Turkish 12–23-month-olds (Karabekiroglu et al., 2009), or in a larger nationwide study according to the primary caregivers’ rating (Karabekiroglu et al., 2013). The similarities between our BITSEA findings and the corresponding results from the two other Western countries may derive from the cultural similarities regarding gender roles and expectations. It is quite usual in the Finnish society, as well as in other Western countries, that although fathers participate in parenting, mothers have more responsibility than fathers regarding governing the family and overseeing the children’s upbringing. Thus, the maternal view, values and “girly” expectations may be seen in both parents’, but particularly in mothers’, higher problem, especially externalizing problem, scores for boys than for girls. On the other hand, the differing results from Turkey are interesting when considering the more traditional parenting culture in the Turkish society compared to the Western countries. One explanation may be found from relatively strong patriarchy in the Turkish culture; due to that both parents may allow “boys to be wild boys” and probable differences between boys’ and girls’ behaviors are not interpreted as essential. However, an international comparison of the parental CBCL reports about preschool children from 24 societies in Asia, Australia, Europe, South-America and the USA demonstrated that boys obtained also globally slightly higher total and externalizing problem scores than girls (Rescorla et al., 2011). Further consistent with our findings, in a publication addressing a large sample of Dutch 3-year-old twin pairs Van der Valk et al. (2001) reported that both mothers and fathers gave significantly higher externalizing problem ratings to boys than to girls. Concerning internalizing problems, parental ratings for boys and girls did not differ (Van der Valk et al., 2001), but in our study, maternal internalizing problem scores were higher for boys than for girls among the toddlers. A comparison between the mean scores of our infant sample and the corresponding BITSEA standardized scores from the USA (Briggs-Gowan & Carter, 2006) indicated that the mean competence and problem total scores by Finnish mothers were in line with the corresponding scores by (mostly) mothers in the USA, both for boys and girls. A comparison between the maternal mean scores of our toddler sample and the standardized scores of 18–23-month-olds revealed that the competence total mean scores for boys were in line in these samples, but for girls the corresponding mean score seemed to be slightly higher in the Finnish sample than in the USA (18.6 vs. 17.7, respectively), although there were 11 boys and 11 girls slightly younger than 18 months in the Finnish toddler sample. The maternal problem total mean scores were lower for the Finnish toddlers, particularly for girls, than for their counterparts in the USA (for boys 8.7 vs. 9.9 and for girls 6.5 vs. 9.2, respectively). Also among the two-year-old Dutch toddlers (Kruizinga et al., 2012), the competence total mean score for boys was very similar with the corresponding mean score for our toddler boys, but for girls the competence total mean score seemed to be slightly higher in the Finnish sample than in the Netherlands (18.6 vs. 17.9, respectively), despite the younger mean age of our toddler sample compared to the Dutch sample. The problem total mean scores of our toddler sample and the corresponding mean scores of the Dutch two-year-olds seemed to be relatively similar, both for boys and girls. Among the Turkish children (Karabekiroglu et al., 2009), the BITSEA competence total mean scores were generally at lower level and the problem total mean scores were at very much higher level (in Turkey 15.4–17.8) than in our samples, in both age and sex groups, and assessed by both parents. The lower BITSEA problem total mean scores for our infant/toddler participants, as well as for the Dutch toddlers, compared to the corresponding scores for the coeval boys and girls in Turkey, and the parallel differences between those scores of our (and the Dutch) toddlers and the 18–23-month-olds in the USA, may be explicable by the relatively high socio-economic status of all inhabitants and the high-quality, inclusive public child health center organization in Finland and the Netherlands. To support this argumentation, Rescorla et al. (2011) reported that both Finnish and Dutch preschool-age children obtained lower CBCL total problem mean scores than children from the USA, and much lower scores than children from Turkey. In our samples, Cronbach’s alpha varied from marginal (0.60–0.70) to adequate (>0.70) for the scale scores, and these alpha values are comparable to those found with the original BITSEA (Briggs-Gowan et al., 2004) and the Dutch version (Kruizinga et al., 2012). Further, we found only poor (≤0.60) internal consistency for the BITSEA problem domains. For the internalizing domain, low alphas may at least partly be due to low base rate of occurrence of some item scorings among our samples. To our knowledge, there are no earlier publications examining internal consistency for these BITSEA domains among general populations, thus, more studies are warranted. Moreover, there are so few items in the BITSEA externalizing, internalizing and dysregulation domains that internal consistency for these domains could not be expected to be very high. However, given the low alphas, the current domain results should be interpreted with caution. The maternal percentage of infant boys in the possible problem range was twice as high as the corresponding percentage of infant girls, and the difference approached also statistical significance. Among the toddlers, both maternal and paternal percentages of boys in the possible deficit range were significantly higher than the corresponding percentages of girls. Furthermore, significantly more boys than girls in both age groups were screened to be in the combined possible deficit and/or problem range by maternal, but not by paternal, reports. When comparing maternal and paternal ratings, fathers perceived significantly more possible deficits in competence among all the toddlers compared to mothers, and the corresponding difference approached significance also among the toddler girls (debated in following paragraphs). When applying the combination of both BITSEA total cut score values standardized by age and sex for the children in the USA, approximately one third of infant boys by both parents’ ratings, one fourth of infant girls and toddler boys by paternal

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ratings, one fifth of infant girls and toddler boys by maternal ratings and only 11–15% of toddler girls by both parents’ ratings were in the possible deficit and/or problem range. These percentages, except for the infant boys, were clearly smaller than the corresponding percentages for children in the USA where the BITSEA has been found to identify about one in three 12–36-month-old children (Briggs-Gowan et al., 2004). The divergence in the percentages in these two countries may reflect the earlier mentioned societal differences. However, it should also be kept in mind that Finnish parents may be more selfcontrolled than parents from the USA when reporting their children’s SEB problems and thus, lower problem total cut score values could be more appropriate for Finnish children. Comparisons between the maternal and paternal BITSEA scores of the infants who were assessed each by both of their parents did not reveal statistically significant differences between the maternal and paternal ratings in any scale or domain, except for the higher maternal internalizing problem scores for the total sample of infants compared to the paternal scores. Among the toddlers who were assessed each by both of their parents, maternal scores were significantly higher than paternal for both boys and girls in the competence total scale. In the problem total scale, as well as in the externalizing and dysregulation problem domains, maternal scores were significantly higher than paternal for the total sample of toddlers, and particularly for boys (also the effect sizes for the differences reached the medium level). Our toddler findings are in line with the previous studies which have demonstrated that mothers tend to report more behavior problems of their offspring than fathers (e.g., Duhig et al., 2000; Earls, 1980; Jensen, Traylor, Xenakis, & Davis, 1988; Van der Valk et al., 2001), particularly concerning boys (Luoma et al., 2004b). Explanations to account the differences between the maternal and paternal BITSEA reports of their child may be divided in three categories: (1) Mother’s and father’s perceptions and/or expectations differ concerning their child’s behavior and skills, (2) The child’s behavior differs toward the mother and father, and (3) There is a difference in the sensitivity and/or specificity of the questionnaire when used with mothers compared to use with fathers. Regarding the category 1, fathers work more often outside home (according to the Official Statistics of Finland (2011), the employment rate was ∼90% for males and only ∼50% for females with the youngest child under 3 years) and spend less time with their young children than mothers. Thus, fathers may be unaware of some of their children’s SEB problems, as well as competencies. On the other hand, differentiation processes are more incomplete between infants and mothers than between older toddlers and mothers. Consequently, mothers may be more “blind” to their infants’ actual behavior compared to older children’s behavior. Thus, mothers’ perceptions of their children’s behavior may be more accurate concerning toddlers compared to infants. Mothers’ and fathers’ tolerances and expectations may also differ regarding their sons’ and daughters’ behavior and skills. For instance, mothers’ tolerance for boys’ wild plays may be lower than fathers’ tolerance explaining our higher maternal problem, especially externalizing problem, scores for toddler boys compared to the paternal scores. In turn, some social–emotional competencies may be more desired and expected to emerge in girls than in boys, particularly by fathers. Thus, girls may be more often induced to learn and show those skills (for example to feed and hug dolls) than boys. As an example of the category 2, children may manifest their feelings and needs more often to their mothers than to fathers, at least if they spend much more time with their mothers compared to fathers. These probable differences in children’s behavior toward the two parents may become more evident when children approach the defiant age. With regard to the category 3, the reliability findings have been quite equal for both maternal and paternal BITSEA ratings so far (in the current study; Karabekiroglu et al., 2009). It is uncertain, if the BITSEA questionnaire works among fathers as well as among mothers in different settings and cultures as to other psychometric properties. Thus, further research is warranted. However, every one of these explanation alternatives may be at least a part of the truth accounting the discrepancies between the maternal and paternal BITSEA ratings concerning our toddler sample, and further research is needed to elucidate the causes behind our results.

4.1. Limitations The most substantial limitation of this research is the limited number of the participants from the one city region, even though the study samples represented the target populations relatively well as to background characteristics. Because the participation was voluntary also to the health care nurses, they were not very active and committed to deliver the BITSEA questionnaires to parents. That was probably the most essential reason for such low participation rates. Another substantial limitation of the current study is that the findings are based on the data from the parent-reported questionnaires only. Consequently, findings of the present study should be generalized to other populations with caution. In addition, mothers seemed to be more active than fathers to attend the study by completing the BITSEA questionnaires. This finding may reflect the earlier mentioned fact that in Finnish families with a young child fathers work more often outside home than mothers, and thus, mothers probably take more responsibility concerning parenting duties. However, differences between the children with and without the paternal BITSEA data were quite minimal as to the available background characteristics. It is also crucial to remember that the BITSEA is a concise first- or second-state screening tool developed for identifying children as at-risk for SEB problems and deficits in social–emotional competence. A further dialogue with the caregivers concerning the screen status of their child should be carried on to determine whether or not the child requires a more comprehensive evaluation of the social–emotional domain or at least follow-up. On the other hand, as strengths of the current study may be considered the relatively young age of the sample subjects and that the equal attention was paid to both maternal and paternal reports of early SEB problems and skills by child sex.

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4.2. Conclusions The findings of the present study indicate that sex differences in the social–emotional/behavior domain may be observed by the parents among children as young as 11 to 24 months of age. Generally, girls obtained higher competence scores than boys, and boys tended to obtain higher problem, especially externalizing problem, scores than girls. Our findings indicate also that among 16–24-month-old toddlers, mothers compared to fathers may perceive more social–emotional competencies in both their boys and girls, as well as more SEB problems in their boys. However, significant differences between the maternal and paternal BITSEA ratings by child sex were not found among 11–17-month-old infants. These findings highlight the importance of paying attention to the probable sex differences when assessing and caring early SEB problems. 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