2013. Vol.4, No.12, 1008-1013
Published Online December 2013 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2013.412146
Prevalence of Behavioural and Emotional Problems among Two
to Five Years Old Kosovar Preschool Children—Parent’s Report
Merita Shala1, Milika Dhamo2
1Faculty of Social Sciences, European University of Tirana, Tirana, Albania
2Psychology Department, Faculty of Social Sciences, University of Tirana, Tirana, Albania
Received October 1st, 2013; revised November 3rd, 2013; accepted November 28th, 2013
Copyright © 2013 Merita Shala, Milika Dhamo. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited. In accordance of the Creative Commons Attribution License all
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Preschool age is characterized by a rapid development in all aspects of child development. During this
development, the introduction of emotional and behavioral disorders can happen to any child. Preschool
children have been a neglected population in the study of psychopathology. The Achenbach System of
Empirically Based Assessment (ASEBA), which includes the Child Behavior Checklist/1.5 - 5 (CBCL/1.5
- 5), constitutes the few available measures to assess preschoolers with an empirically derived taxonomy
of preschool psychopathology. The study was based on an age- and gender-stratified sample of 755 chil-
dren aged 1.5 - 5 years from five municipalities of Kosovo. The CBCL/1.5 - 5 form was voluntarily com-
pleted by the parents of 426 or 56.4% boys and 329 or 43.6% girls. There were 639 or 84% mothers and
116 or 15.4 % fathers. The prevalence of total problems was estimated as 2.9%, the prevalence of exter-
nalizing behavior problems was 2.5%, while the prevalence of internalizing behavior problems was 3.8%.
These results are low compared to other international studies. The results revealed that there are not sig-
nificant differences in mean scores among boys and girls on total problems, internalizing and externaliz-
ing. Regarding the age, there are statistical differences within the decreasing of age among the three
broad-bands syndromes. Such findings highlight the way in which preschool behavior problems may vary
within specific cultural settings and underscore the need for in-depth research to explore the contexts.
Keywords: CBCL; Preschool Children; Behavior Problems; Internalizing; Externalizing
Social-emotional development captures a broad swath of spe-
cific outcomes, ranging from the ability to identify and under-
stand one’s own and others’ feelings, establish and sustain rela-
tionships with both peers and adults, and regulate one’s behav-
ior, emotions, and thoughts (National Scientific Council on the
Developing Child, 2005). In the literature, children’s behav-
ioural and socio-emotional adjustment is generally indicated by
the extent of their manifestation of behaviour problems (Camp-
bell, 1995; Dearing, McCartney, & Taylor, 2006). Behaviour
problems have often been conceptualized along two broad spec-
trums: internalizing problems which are expressed in intraper-
sonal manifestation, such as anxiety, depression and with-
drawal; and externalising problems which are demonstrated in
interpersonal manifestation, such as hyperactivity and aggres-
sion (Achenbach, 1991; Achenbach & Rescorla, 2000; Dearing
et al., 2006). It has been reported that approximately 5% to 14%
of kindergarten children in the general population exhibit mod-
erate-to-severe behavioural problems (Lavigne et al., 1996; Luk
et al., 1991) while Campbell (1995), states that approximately
10% - 15% of preschool children are mild to moderate behavior
problems. In a comprehensive review of studies about the
prevalence of psychiatric disorders, Roberts et al. (1998) re-
ported prevalence rates of preschool children between 3.6% and
24% with a mean of 10.2%.
The literature is more inconsistent about gender differences
during the preschool period (Campbell, 1995). The literature
suggests that boys and girls often manifest different health,
mental health, social, and behavior problems (Baillargeon et al.,
2007; Maschi et al., 2008). Some studies have shown that girls
are much more likely to cope with stress using internalizing
behaviors (e.g., anxiety and depression) while boys are more
likely to use externalizing behaviors (e.g., anger or aggression)
(Hoffman & Su 1997; Moffitt et al., 2001). Furthermore, other
research has reported a significant correlation between inter-
nalizing and externalizing problems (e.g. Achenbach & Res-
corla, 2000; Mesman, Bongers, & Koot, 2001). Achenbach and
Rescorla (2000) found a positive correlation between internal-
izing and externalizing scores among a national US sample,
suggesting that children tend to score similarly in both areas of
Another body of research has revealed gender differences in
behaviour problems, especially in externalizing behaviour. For
instance, it has been reported that boys tend to manifest exter-
nalizing problems more than girls (Prior, Smart, Sanson, &
Oberklaid, 1993). Keenan and Shaw (1997, 2003) argued that
gender differences in externalizing behavior are not apparent
until toddlerhood and become more pronounced in preschool.
M. SHALA, M. DHAMO
Although gender differences in externalizing problems are well
documented (see Maccoby, 1998), relatively little is known
about these behaviors in girls (Hinshaw, 2002). In the toddler
and preschool years, sex differences are not as marked as in
older children. Boys’ higher rates of disruptive behavior seem
to emerge during the later preschool period, with studies docu-
menting absence of sex differences from age 1 to 3 (Achenbach,
1992; Keenan & Shaw, 1994), followed by increasing sex dif-
ferences from age 4 to 5 (Lavigne, Gibbons, Christoffel et al.,
1996; Rose, Rose, & Feldman, 1989).
Several studies are available which indicate that early emer-
gent behaviour problems are linked with serious behaviour
problems later in life (Duncan, Brooks-Gunn, & Klebanov,
1994; Stormont, 2002). In support of this is the finding that
50% to 75% of kindergarten children with significant behaviour
problems continue to have these difficulties up to 7 years later
(Marakovitz & Campbell, 1998; Speltz, McClellan, DeKlyen,
& Jones, 1999). Other research (Zoccolillo, Tremblay, & Vitaro,
1996) has further revealed that the stability and continuity of
these behaviour problems can further negatively affect chil-
dren’s psychological, cognitive and behavioural outcomes, in-
cluding poor academic competence, delinquency and conduct
Individual perceptions of what constitutes problem behavior
can also vary. This concern is particularly important because
most research on childhood behavior problems utilizes parental
reports, and parents’ perceptions of the appropriateness, sever-
ity, and quality of their child’s behaviors are influenced by
many factors. It is possible that the measurement and assess-
ment of behavior problems could be influenced by cultural
factors that vary by ethnicity (Spencer, Fitch, Grogan-Kaylor,
& McBeath, 2005).
In fact, an understanding of the developmental origins of
later psychopathology can be gained through research into the
early signs of social and emotional dysfunction, and consider-
ing that most of our children start to attend preschool institu-
tions when they are three years old, we designed the present
study to determine prevalence rates of behavioural and emo-
tional problems according to parent’s report. Our hypothesis
was that there will be differences between the girls and the boys
on total problems, internalizing and externalizing.
Sample and Procedure
From a total of 755 children, there were 426 boys or 56.4%
and 329 girls or 43.6 [(mean age in years = 3.4 (SD 1.0)] from
five municipalities (Pristina, Peja, Ferizaj, Mitrovica, Gjilan),
who took part in the study. Children ranged in age from 2 to 5
years old (2 = 183 children; 3 = 221 children; 4 = 233 children;
5 = 118 children). There were 755 participants’ parents who
voluntarily completed a socio-demographic questionnaire, and
rated their child’s behavior on the Achenbach Child Behavior
Checklist (CBCL 1.5 - 5). The response participation rate was
75.5%. As expected, 639 or 84% of parents were mothers and
116 or 15.4 % were fathers. Table 1 presents the education
level and employment rate for both parents.
Table 1 shows that from 755 mothers, only 3 of them have
the elementary level of education, while 752 of them are very
well educated. We can say the same thing for the fathers as well,
out of 755, 272 of them have secondary school level while 479
of them have university degree.
Education level and employment rates for parents.
Education level mother
Elementary 3 0.4
Secondary school 165 21.9
University degree 587 77.7
Education level father
Elementary 4 0.5
Secondary school 272 36.0
University degree 479 63.5
Employment situation mother 736 98.1
Employment situation father 752 99.6
Prior to collection of the survey data, we granted the permis-
sion for using Kosovar version of CBCL 1.5 - 5. From No-
vember 2012 to May 2013 the researcher visited the preschool
institutions in five municipalities that were selected from the
list provided by Ministry of Education Science and Technology.
The researchers met with each preschool director to explain the
aim of the study and establish mutual cooperation. Then, the
preschool director offered the CBCL to parents of preschool
children who attended the preschool institution.
The ASEBA (Achenbach System of Empirically Based As-
sessment) preschool forms are standardized assessment instru-
ments that are user-friendly, cost-effective, and usable by a
wide range of professionals in different settings, which can be
completed independently by most respondents in about 15 - 20
min. CBCL 1.5 - 5 were designed to provide normed scores on
a wide array of behavioral and emotional problem scales in
young children (Rescorla, 2005). The CBCL for preschoolers
has been used in over 200 published studies and its validity and
reliability are well documented (Rescorla, 2005).
Parent ratings were obtained using the CBCL 1.5 - 5 (Achen-
bach & Rescorla, 2000), which has 99 items rated 0-1-2 (0 =
not true (as far as you know); 1 = somewhat or sometimes true;
or 2 = very true or often true) plus 1 open-ended problem items.
Ratings of CBCL 1.5 - 5 problem items are based on the chil-
dren’s functioning over the preceding 2 months. Parents com-
pleted the questionnaires on a voluntary basis at home. They
were asked to turn it to the preschool teacher, who collected
and sent them to the director.
Six syndromes of co-occurring problems were identified for
the CBCL 1.5 - 5 through exploratory and confirmatory factor
analysis of item ratings (Achenbach & Rescorla, 2000). Sec-
ond-order factor analysis of the six syndromes yielded two
broad-band groupings: Internalizing (comprised of the Emo-
tionally Reactive, Anx ious/Depressed, Somatic Complaints, and
Withdrawn synd rome s) and Externalizing (comprised of the
Attention Problems and Aggressive Behavior syndromes). The
Total Problems scale is the sum of the ratings on all problem
T scores and raw scores were assessed using Assessment
Data Management (ADM) and all other statistical analyses
Open Access 1009
M. SHALA, M. DHAMO
were carried out by SPSS version 19 for Windows. Cronbach’s
alpha (α) coefficient was used as an index of internal consis-
tency for the CBCL. Scales were described by mean and stan-
dard deviation (SD). Multivariate analyses were computed by
means of the general linear model (GLM).
To compare broadband and syndrome scales all CBCL scores
were transformed into T-values. Table 2 displays the mean
scores, standard deviation and the internal consistency for the
seven syndrome scales and the three broad band syndromes.
The mean of the CBCL total score of the complete sample
was 34.2 (SD = 22.6). As shown in Table 2, there is obviously
a high level of internal consistency on both scales.
Further on, two main effects, gender and age, had no signifi-
cant interaction, F (1) = 2.91, p = .088. There was no significant
correlation between the gender of the children and the CBCL
total score (rs = −0.03, p = 0.32), while there was a significant
correlation between the age of the children and the CBCL total
score (rs = 0.13, p = 0.00). The results for mean scores and
standard deviations for three broad-band scales by gender are
shown in Table 3.
The gender differentiated norms leveled the CBCL total
scores of boys (Mean = 33.5, SD = 23.1) and girls (Mean =
35.1, SD = 21.9) and there was no significant difference t =
0.98, p = 0.325. It’s the same thing for INT scale, were the t =
= 0.106 and also for the EXT scale were t = −0.624, p
0.533. These results are inconsistent with the hypothesis. The
scores of the two broadband scales, for all children, the INT
and the EXT scale were significantly correlated: r = 0.66, p <
0.01. We can say the same thing also for girls, were the correla-
tion is: r = 0.64, p < 0.01 while for the boys the correlation is r
= 0.69, p < 0.01. For the girls the means of the two broadband
scales did not differ significantly: INT = 11.6; EXT = 11.2; t =
1.077; p = 0.282. For the boys the mean of EXT (11.5), was
significantly higher than the mean of INT (10.6), t = −3.083, p
< 0.002. On both broadband scales the means of boys and girls
did not differ significantly, INT: Mboys = 10.6, Mgirls = 11.6; t =
1.61, p = 0.106; EXT: Mboys = 11.5, Mgirls = 11.2; t = −0.624, p
The results obtained through analysis of variance indicated
significant main effects for age. As shown in the Table 4, older
children had a higher mean Total Problems score than younger
children, F (1) = 5.3, p < 0.001, η2 = 0.02. The ANOVA for
internalizing yielded significant main effects for age. Older
children had a higher mean internalizing score than younger
children F (1) = 6.3, p < 0.001, η2 = 0.02. We can say the same
thing for the ANOVA results for externalizing, F (1) = 4.2, p <
0.001, η2 = 0.01.
The results obtained through analysis of variance [2 (gender)
× 4 (age group)], on seven empirical scores indicated signifi-
cant main effects for age, the emotional reactive and somatic
complaints indicated significant main effects for gender, while
sleeping problems indicated significant main effects on both,
gender and age. As shown in the Table 5, the values presented
decrease with increasing age of the children, so the younger
children have shown the higher mean than older children for all
For emotionally reactive, F (1) = 4.2, p < 0.00, η2 = 0.01, age
* gender interaction was found significant: F (1) = 5.6, p <
0.001, η2 = 0.02; for anxiety scores, ANOVA indicate the same
The mean scores, standard deviation and the internal consistency for the
syndrome scales and the three broad band syndromes.
Mean (SD) Cronbach’s alpha (α)
Emotional 2.4 (2.5) 0.88
Anxiety/depression3.5 (2.7) 0.87
Somatic complaint3.1 (2.5) 0.88
Withdrawn 2.0 (2.4) 0.88
Sleep problems 3.0 (2.4) 0.88
Attention problems2.3 (1.8) 0.88
Aggressive behavior9.0 (6.1) 0.86
Internalizing 11.0 (8.6) 0.86
Externalizing 11.4 (7.4) 0.86
Total problems 34.2 (22.6) 0.93
Mean scores and standard deviations for three broad-band scales by
GenderN Mean SD
F 32935.1 21.9
Problems M 42633.5 23.1
F + M75534.2 22.6
F 32911.6 8.4
Internalizing M 42610.6 8.8
F + M75511.0 8.6
F 32911.2 7.6
Externalizing M 42611.5 7.3
F + M75511.4 7.4
Mean scores and standard deviations for three Broad-band scales by
2 years 9.7 (9.2) 11.0 (6.8) 32.2 (21.8)
3 years 9.8 (6.6) 10.7 (6.5) 30.9 (17.8)
4 years 12.0 (8.1) 11.3 (7.5) 35.3 (21.5)
5 years 13.4 (10.9) 13.5 (9.2) 41.1 (31.2)
result: F (1) = 22.7, p < 0.00, η2 = 0.07, age * gender interaction
was found significant: F (1) = 3.7, p < 0.01, η2 = 0.01; for
withdrawal: F (1) = 6.7 , p < 0.00, η2 = 0.02, , age * gender
interaction was found significant: F (1) = 12.4, p < 0.00, η2 =.05;
for attention problems: F (1) = 2.9 , p < 0.03, η2 = 0.01, age *
gender interaction was found significant: F (1) = 7.2, p < 0.00,
η2 = 0.03; and for the aggression: F (1) = 11.5, p < 0.00, η2 =
0.04, age * gender interaction was found significant: F (1) = 9.4,
p < 0.00, η2 = 0.04.
The sleeping problems and somatic complains indicated sig-
nificant main effects for age and gender. Sleeping problems for
gender: F (1) = 32.0, p < 0.00, η2 = 0.04; and for age: F (1) =
4.0, p < 0.00, η2 = 0.02. For Age * gender no interactions were
Somatic complaints for age: F (1) = 3.2, p < 0.02, η2 = 0.01.
M. SHALA, M. DHAMO
Girls had a higher mean than boys: F (1) = 4.8, p < 0.03, η2 =
0.00. Age * gender interaction was found significant: F (1) =
6.9, p < 0.00, η2 = 0.03.
For Internalizing, Externalizing, and Total Problems, we
used the clinical range defined as T scores ≥ 64 (about the 90th
percentile), the borderline range = T scores from 60 to 63 (84th
to 90th percentiles, and the normal range = scores below the 84th
percentile (T < 60). With this cut-off, 2.9% of children scored
in the deviant range. This percentage provided an estimate of
the prevalence of emotional and behavioral problems in Kos-
ovar children according to parents’ rating. Prevalence rates
were 3.8% for Internalizing problems and 2.5% for Externaliz-
ing. The results are presented in Table 6 for Internalizing, Ex-
ternalizing, and Total Problems by gender and age.
Table 6 shows the prevalence rate for scores above the
cut-off for deviance on Internalizing, Externalizing, and Total
Problems separately by gender and age. For Internalizing,
prevalence was higher for girls than boys and for three, four
year old children higher than for younger and older children.
For Externalizing, prevalence was much higher for boys than
girls, and slightly higher for younger children than older chil-
dren. For Total Problems, prevalence was slightly higher for
girls than boys, and there is a big difference for four years old
children, while for the other groups the prevalence is compara-
With a very low rate, only 2.9% of the preschool children
were in the clinical range on the CBCL 1.5 - 5. In comparison
to a previous research with 360 children from the municipality
of Pristine (Jetishi, 2010), using the same measure, this rate is
low. Within the previous study (Jeshiti, 2010) the prevalence
rate for total problem scores were 7.2% in the clinical range,
while in this study 2.9. This can be explained with the fact that
our research included 755 children from five different munici-
palities of Kosovo, all children who already attend a preschool
education program, which is expected to have its impact on
Means and standard deviation for seven empirical scales, according to
gender and age.
Emotional 2.5 (2.6) 2.2 (2.4) 1.8 (2.6) 2.2 (2.2) 2.5 (2.2)3.0 (3.1)
depression 3.7 (2.8) 3.4 (2.7) 3.3 (3.0) 3.2 (2.3) 3.7 (2.8)4.1
complaint 3.4 (2.3) 2.9 (2.7) 2.8 (2.4) 2.9 (1.8) 3.2 (2.4)3.7 (3.5)
Withdrawn 2.0 (2.4) 2.0 (2.5) 1.7 (2.5) 1.5 (1.9) 2.6 (2.3)2.5 (2.9)
problems 3.5 (2.7) 2.6 (2.1) 2.9 (2.6) 2.7 (2.4) 2.9 (1.9)3.6 (2.9)
problems 2.4 (1.9) 2.4 (1.8) 2.1 (1.7) 2.2 (1.6) 2.4 (1.8)2.8 (2.4)
behavior 8.9 (6.2) 9.2 (5.9) 8.9 (5.7) 8.5 (5.4) 8.8 (6.2)10.7
Prevalence (%) of scores above the cut-off for Internalizing, External-
izing, and Total Problems by gender and age.
Internalizing Externalizing Total
Nr. % Nr. % Nr. %
Boys 15 3.2 21 4.4 20 4.2
Girls 15 4.6 5 1.5 15 4.6
2 years 8 4.4 6 3.3 8 4.4
3 years 13 5.9 7 3.2 10 4.5
4 years 11 4.7 7 3.0 4 1.7
5 years 5 4.2 3 2.5 5 4.2
Total 29 3.8 19 2.5 22 2.9
child development and behavior. However, the other demo-
graphic variables should be considered.
We can say the same thing for the comparison with interna-
tional studies, with research showing the range from 7% - 25%
(Angold & Egger, 2004) and 11.9% of Turkish Children (Erol
et al., 2005). The prevalence rate of this study was too far from
the range of 10% - 15% reported by Campbell (1995) and from
10.2%, which was the mean prevalence in preschool studies
reviewed by Roberts et al. (1998).
Notwithstanding cross-national comparisons of studies, it is
of interest in the current study that the mean Total Problems
score of 34.2 (SD = 22.6) for 2 - 5 years old Kosovar children
was slightly higher than the mean Total problems score for
Dutch children, which was 30.5, also for 466 Italian children it
was 33.4 (Frigerio et al., 2006), for 374 Finnish children
(Sourander, 2001), was 30.4, while for 109 Icelandic children
the mean score was 27.5 (Hannesdóttir & Einarsdóttir, 1995)
and for 756 Quebec children, it was 32.9 (Larson et al., 1988).
On the other side, our result was lower than in some other
studies. Namely, the mean Total Problems score for 169 Span-
ish children from the general population, was 37.6 (De la Osa,
Ezpeleta, & Navarro, 1996), while Erol et al. (2005) obtained a
total problems mean score of 39.5 for 638 Turkish children
assessed with CBCL 2 - 3.
There was an obvious tendency of increase of internalizing
values within the age, which could be explained and may re-
flect improvements in the capacity to remember and anticipate
negative events (Kaslow, Brown, & Mee, 1994). For external-
izing problems there was a slight decrease of values, which
corresponds with developing language and cognitive abilities
that permit the use of emotion regulation strategies other than
physical aggression to settle disputes. Regarding the gender
differences there was no statistical significance for any of the
three broad band syndromes. This was in line with a body of
studies (Campbell, 1995; Keiley et al., 2000; Richman et al.,
1982), that there are no gender differences in preschool children,
and disagreed with some other studies, which reported that boys
tend to demonstrate a significantly higher propensity to mani-
fest externalizing problems than girls (Prior, Smart, Sanson, &
Oberklaid, 1993; Sanson, Oberklaid, Pedlow, & Prior, 1991).
In our context, having into consideration that out of 755, 639
respondents were mothers, and that our mentality encourages
boys to be more lively, more active than girls, this result is of
interest to further studies. Also from the fact that we used only
parent’s report, while it has been argued that multi-informant
assessment of children may offer a more comprehensive under-
Open Access 1011
M. SHALA, M. DHAMO
standing of children’s problems (Kagan, Snidman, McManis,
Woodward, & Hardway, 2002), and that modest to moderate
strength of correlations across informants and across settings
(Achenbach, Edelbrock, & Howell, 1987; Grietens et al., 2004)
may reflect true variations in children’s behaviors across dif-
ferent settings and interpersonal relationships (Kerr, Lunken-
heimer, & Olson, 2007; Merrell, 1999), we strongly recom-
mend a multi-informant assessment of Kosovar preschool chil-
Despite the large sample size, restrictions must be made
about the generalizability of the findings. The study sample was
derived from preschool institutions and there is a very low per-
centage of preschool attendance in Kosovo. The educational
levels of parents and a predominantly middle class bias were
specific features of the sample. Also the rate of employment
was clearly higher than the national average.
When interpreting the results, it should be taken into account
that the child mental health status was assessed by a symptom
checklist questionnaire. Given the large number of subjects, the
questionnaire approach offers useful information but lacks the
specificity and additional depth that structured psychiatric in-
terviews might provide.
Further studies on preschool children behavior problems are
strongly recommended in order to understand the continuity
and discontinuity of CBCL scores as the children develop.
The authors gratefully acknowledge the participants in the
study as well as preschool institution directors and teachers. We
would also like to express special appreciation to Emina Hyseni
for continuous support with translation and proofreading.
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