Anxiety, depression and other internalizing problems of young children in low and middle-income countries before the covid-19 pandemic

doi:10.21203/rs.3.rs-5006281/v1

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Systematic Review

Anxiety, depression and other internalizing problems of young children in low and middle-income countries before the covid-19 pandemic

https://doi.org/10.21203/rs.3.rs-5006281/v1

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Introduction:

This study addresses the scarcity of research on the characteristics of young children's internalizing problems in Low and Middle-Income Countries (LMICs) through a systematic review of pre-pandemic literature. It aims to provide essential insights into understanding, preventing, and intervening in internalizing problems among young children. Additionally, it lays the groundwork for future studies to explore the effects of the pandemic on mental health in young children, including potential changes in the prevalence and nature of internalizing problems.

Methods:

The systematic review included thirty-one studies from LMIC studies published in English, Spanish, or Portuguese before March 2020 focusing on predictors, mediators, and characterizations of internalizing symptoms in preschoolers. The studies were classified by region to identify commonalities, interests, and differences.

Results:

The review revealed a significant disparity in research representation across regions, with the Americas being the most extensively studied and regions like the Eastern Mediterranean and Southeast Asia lacking adequate research. Validation of behavioral problem scales in LMICs was limited, posing challenges to accurate measurement. However, findings highlighted common risk factors such as maternal characteristics and environmental influences.

Conclusions:

Despite limitations, this review emphasizes the urgent need for comprehensive research on internalizing problems in preschoolers, particularly in LMICs. Broadening linguistic inclusion criteria and prioritizing validation efforts for behavioral problem scales are crucial steps towards addressing research gaps. Furthermore, highlighting common risk factors and patterns across regions underscores the importance of collaborative efforts to inform effective interventions and support child mental health globally.

Child behavior

preschool mental health

underserved population

parent-child relationship

Our research addresses a critical gap in early childhood mental health studies by exploring internalizing problems in preschool-aged children within LMICs. Conducting a systematic literature review published before March 2020, our aim is to illuminate the prevalence, predictors, and structural aspects of internalizing problems in these contexts. Undertaking this review pre-pandemic establishes a foundational understanding of internalizing problems in LMICs, vital for informing subsequent studies assessing preschoolers' mental health amidst global crises like the COVID-19 pandemic.

Furthermore, our research sheds light on key risk factors associated with internalizing problems in LMICs, such as parental psychopathology and exposure to violence. These insights offer valuable guidance for developing preventive strategies and targeted interventions aimed at mitigating the adverse impact of internalizing problems on preschool-aged children's health and well-being.

Additionally, we emphasize the necessity for culturally sensitive assessment tools tailored to diverse populations within LMIC contexts. These tools are essential for accurately identifying and addressing internalizing problems, facilitating early intervention and support.

In summary, our research deepens our understanding of factors shaping mental health outcomes among preschool-aged children in LMICs and advocates for increased focus and resource allocation in this critical area to foster improved mental health outcomes globally.

Depressive and anxiety disorders are among the main threats to public health across the globe due to the combination of their high prevalence and serious adverse effects(Organization, 2017; Vigo et al., 2016; Vos et al., 2016). There is a growing body of research on their predictors, effects of depression and anxiety, as well as their treatment in adolescents and adults. Although there is evidence that children can have clinically significant internalizing symptoms as early as preschool years(Denham, 1998; Kashani et al., 1986; Keenan et al., 1998), research on internalizing problems in young children is scarce.

Adverse effects of internalizing problems in preschoolers have been identified, such as school absenteeism and inadequate adaptation skills, have negative effects on children’s general health and wellbeing.(Gonzálvez et al., 2018; Groh et al., 2012; Kopala-Sibley & Klein, 2017; Morales & Wang, 2018; Norman et al., 2012), their potential continuation in adolescence, and their potential development into chronic mental disorders in later years.(Ashford et al., 2008; Slemming et al., 2010; Sterba et al., 2007) However, we know little about the characteristics and predictors of internalizing problems since they are rarely studied as outcomes. In addition, they are commonly studied as a single variable (presence/absence of clinically significant internalizing problems (Foland-Ross et al., 2016; Murray et al., 2009; Organization, 2017; Tandon et al., 2009)), hindering the understanding of their characteristics and decreasing diagnostic and therapeutic accuracy.

Internalizing symptoms in preschoolers draw less attention than other child behaviors because these children do not usually display overtly socially disruptive behaviors (Tandon et al., 2009) and they are challenging to observe directly, unlike externalizing problems. Internalizing problems often play a role secondary to externalizing problems in studies of early child behavior, and due to their high comorbidity, they tend not to be studied separately. Some authors have suggested that a single dimension of psychopathology better explains psychopathology in adolescents and adults(Caspi et al., 2014; Martel et al., 2017; Starr et al., 2014), but whether that is the case in preschoolers remains unexplored.

In LMICs, health research focuses on issues perceived as directly threatening the lives of their populations i.e. infectious diseases, chronic diseases, drug use, and lack of access to essential health services.(Daniel Fatori et al., 2019; Razzouk et al., 2010) Compared to High Income Countries (HICs) or more developed economies, there are fewer studies and lower rates of mental health treatment in adults(Semrau et al., 2015; Wainberg et al., 2017), and many fewer studies of mental health in young children in LMICs. Due to the scarcity of research on mental health in young children in LMICs, studies with populations in HICs serve as the basis and sometimes as the only sources of evidence to make decisions regarding health policies and treatment access (Ali et al., 2016; Docherty et al., 2017; McDaid et al., 2008).

Different patterns may be found in LMICs compared to HICs in the prevalence of known risk factors of internalizing problems in preschoolers (such as parental psychopathology, violence, lack of emotional and financial support, and other adverse events(Bifulco et al., 2002; Burke et al., 2005; Chioda, 2017; Contributors, 2019; Cruz, 2016; Giménez, 2016; Hillis et al., 2016; Krishnan & Nestler, 2008; Lansford et al., 2014; Muggah & Tobón, 2018; Neumann & Landgraf, 2012; NIMH, 2017; Rathod et al., 2017; Rivera, 2016)), the probability of other risk factors, their consequences, and their structure. In addition, the mental health of LMICs populations may have been differently affected by the COVID-19 pandemic. The high prevalence of known risk factors of internalizing problems found in LMICs and the new threats to the population's health, such as COVID-19, place millions of preschoolers at risk of suffering internalizing problems and their negative consequences.

Reviewing what is known on characteristics, structure, and predictors of internalizing problems in preschoolers in LMICs will identify and address gaps in knowledge and describe the landscape before the pandemic in order to inform future studies on its mental health effects. We conducted a systematic literature review including studies written in English, Spanish, and Portuguese, assessing prevalence, predictors, or structure of internalizing problems in preschoolers in LMICs published before March of 2020.

We searched for all studies up to February 16, 2020, written in English, Spanish, and Portuguese, using combinations of the following keywords/terms in Pubmed, Embase, PsycINFO in EBSCOhost, SciELO, and Bireme: 1) internalizing disorders related terms: internalizing symptoms, internalizing problems, anxiety, depression, emotional symptoms, behavioral symptoms; 2) preschool related terms: nursery, kindergarten, playschool, pre-primary school, preschool-age; and 3) low and middle-income countries, developing country, developing economy. For all keywords, filters, and expanders used, see Appendix 1.

Two independent reviewers with experience in child psychiatry (D.M.) and psychiatric epidemiology (A.M.M.) carried out the selection of articles. Preschoolers were defined as all children who had not yet started primary school (range 1.5 to 6-years-old). Inclusion criteria were studies of preschoolers living in LMICs addressing prevalence, predictors, or structure of internalizing problems in all children provided that estimates for internalizing symptoms in preschoolers could be isolated from externalizing symptoms or total difficulties.

Exclusion criteria were studies in samples of children with developmental disabilities, schizoaffective disorders, specific samples (e.g., only mistreated children), case studies, genetic studies, medication effects, treatment effects, conducted in countries not considered developing economies according to the International Monetary Fund and the United Nations, written in a language other than English, Spanish or Portuguese, and not published in peer-reviewed journals or other grey literature.

The resulting list of publications was exported from each database into EndNote to format references and exclude duplicates and then exported into Covidence(Innovation, 2018) to discard papers by title and abstract, and full-text screening. Both reviewers described the reason for exclusion, selected for data extraction, and rated the quality of the studies using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies(National Heart & Institute, 2014) and the PRISMA Checklist(Liberati et al., 2009).

Our interpretation of the findings is based mainly on the structure of the Child Behavioral Checklist (CBCL 1.5-5)(Achenbach & Rescorla, 2000), the most commonly used instrument to measure behavior problems in preschoolers worldwide. Five LMICs have reported validation studies supporting the structure of the CBCL 1.5-5: China, Peru, Turkey, Kosovo(Ivanova et al., 2010), and Mexico(Albores-Gallo et al., 2016). Behavioral problems corresponded to three factors or dimensions: internalizing problems, externalizing problems, and sleep problems. Internalizing problems are composed of four syndromes: anxiety/depression, somatic complaints, withdrawn, and emotionally reactive. Each of the three dimensions and the four syndromes has a CBCL score and cutoff points that determine if the problems are clinically significant, subclinical, or non-clinical.

From the search with English keywords, we obtained 507 titles, with Spanish keywords, 97 titles, and with Portuguese keywords, 37 titles, adding up to 641 references.

Of the 641 references retrieved, there were 222 excluded duplicates. One paper was added from an external source. Of the 420 articles screened, 328 were excluded based on title and abstract. Of the 92 studies selected for full-text review, 31 were included in the study and selected for extraction. The main reasons for exclusion were that the study was not in an LMIC and it was not possible to isolate an effect in preschoolers, and written in a language other than English, Spanish, or Portuguese (either Chinese Mandarin, Arabic, Persian, or Turkish). (See Fig. 1).

General Characteristics of the Studies

The 31 studies were classified according to their WHO region (Organization, 2017): the Americas, Africa, European, and Western Pacific. No studies from the Eastern Mediterranean region or the Southeast Asia region were selected (see Appendix 1).

The region of the Americas had the largest proportion of studies selected (45%). The country with the majority of included studies was Brazil (19%). Most of the papers (74%) were written in the last ten years. Notably, the number of studies would have been greater if studies in Mandarin Chinese or Turkish had been included (respectively, five and four studies were selected). We also found that the large majority (80%) of studies used versions of the CBCL even if the instrument was not validated for use in their study population. This means that based on validation efforts, only xx of the studies worked with a validated More than 30% of the studies had small samples of fewer than 100 people recruited in a single preschool/institution or small areas. The small sample sizes may represent a specific geographic area, and the studies could be of good quality but may not allow for the extrapolation of results to similar populations.

One study examining internalizing problems in preschoolers in 24 countries(Rescorla et al., 2011) found that the six with the highest mean internalizing scores were Singapore, Iran (LMIC), Romania (LMIC), Lithuania, Turkey (LMIC), and Chile, and reported that the estimated means of internalizing problems in these six countries did not differ significantly from each other.

For a detailed description of all the findings, see Tables 1 to 4.

Region of the Americas

Seven of the fourteen studies in the Americas were written in Spanish, five in English, and two in Portuguese. Four of the five studies in English were conducted in Brazil, (six, or 43% of the studies in this region). Eleven studies were cross-sectional, and only three were longitudinal. Regarding sample size, six studies (43% of the studies in this region) had samples of fewer than 100 participants. The studies with larger samples were all conducted in Brazil. The majority (57%) were of fair quality based on the Quality Assessment tool(National Heart & Institute, 2014) and the PRISMA checklist.(Liberati et al., 2009)

Prevalence of Internalizing problems and syndromes in the region

Only two studies (Matijasevich et al., 2014; Santos et al., 2015), both conducted in Brazil with representative samples of a city (one in Pelotas, Rio Grande, in 2004 (n = 3,750), and one in Salvador, Bahía, in 2001 (n = 349), described the prevalence of internalizing problems in preschoolers. Their estimates were 7.8%(Matijasevich et al., 2014) and 9.7%(Santos et al., 2015). respectively. Other studies(El Rafihi-Ferreira et al., 2016; Lacunza, 2011; Lins & Alvarenga, 2015) described the prevalence of internalizing problems but had fewer than 100 participants, or they were not representative samples.

The study conducted in Pelotas compared two cohorts and reported a significant increase of 10% in the internalizing problem scores over eleven years (between 1993 and 2004) (Matijasevich et al., 2014), but not in the prevalence of clinically significant cases (from 5.6 to 7.8%). One study conducted in Mexico City(Gil Rodríguez et al., 2018) with 60 dyads of mothers and their children found a mean score of internalizing problems of 56.38 (SD = 9.08) on the CBCL. Assuming a normal distribution, about 16% of the children may have internalizing problems in the clinical range (≥ 64).

Three studies(Markovic et al., 2016; Montoya Arenas et al., 2014; Santos et al., 2015) described the most frequent internalizing syndromes in preschoolers; they included two in Brazil with representative samples (Markovic et al., 2016; Santos et al., 2015) and one study in Colombia with a small sample (n = 20)(Montoya Arenas et al., 2014). The two Brazilian studies found that the most common internalizing problem was being withdrawn. The other study, conducted in Colombia (n = 20), found that based on parental reports, the most common internalizing problem in preschoolers was somatization, but based on teacher reports, the most common internalizing problem was depression(Montoya Arenas et al., 2014).

The remaining studies did not provide mean scores or prevalence estimates of internalizing problems or syndromes. Instead, their focus was to make comparisons and estimate associations, as described below.

Risk factors studied in the region of the Americas

Studies in this region focused on examining the risk of internalizing problems according to child characteristics and the home environment. The child’s characteristics examined were: deficits in social skills(Lacunza, 2011) and sleep disturbance(El Rafihi-Ferreira et al., 2016) as well as persistent difficulties in the child’s ability to respond, lack of involvement in activities, and .diminished general emotional availability (Gil Rodríguez et al., 2018). The home environment characteristics examined were: maternal age, paternal age, number of siblings(Lins & Alvarenga, 2015), maternal psychopathology, absence of father(Santos et al., 2015), socioeconomic status (SES)(Matijasevich et al., 2014), early adversity(Corapci et al., 2006), and bed-sharing(Santos et al., 2017).

Significant relationships with the child’s characteristics were in the expected direction; general internalizing problems were associated with a deficit in social skills(Lacunza, 2011), sleep disturbance(El Rafihi-Ferreira et al., 2016), difficulties in child’s ability to respond, child’s involvement in activities, and child’s general emotional availability (Gil Rodríguez et al., 2018). Child’s ability to respond was protective against the anxious/depressed syndrome, and child’s emotional availability was protective against the withdrawn syndrome (Gil Rodríguez et al., 2018).

Significant relationships were also in the expected direction with respect to the home environment variables, such that risky exposures were associated with high internalizing problem scores (e.g., controlling criticism in the mothers, lower maternal education (Lins & Alvarenga, 2015), absent father (Santos et al., 2015), dyadic emotional availability (Gil Rodríguez et al., 2018)). Persistent and early onset bed-sharing were associated with increased odds of internalizing problems(Santos et al., 2017). One study(Santos et al., 2015) found a significant association between maternal psychopathology and externalizing problems, but not with internalizing problems. Regarding specific syndromes, there were negative relationships between maternal age and somatic complaints (Lins & Alvarenga, 2015), maternal education and withdrawn(Lins & Alvarenga, 2015), and between SES and anxious/depressed syndrome(Matijasevich et al., 2014).

Assessment of Confounding

In most of the selected studies, there was no assessment of confounding, or it was not reported. Only four studies (29% in the region) (Matijasevich et al., 2014; Pearson et al., 2019; Santos et al., 2017; Santos et al., 2015), conducted in Brazil, described the assessment of confounding and/or provided adjusted estimates. Included confounders were family income (Pearson et al., 2019; Santos et al., 2017; Santos et al., 2015), marital status (Matijasevich et al., 2014; Pearson et al., 2019), maternal age (Pearson et al., 2019; Santos et al., 2015), child’s age(Matijasevich et al., 2014; Santos et al., 2017), schooling, skin color, depressive symptoms, smoking during pregnancy, type of delivery (Santos et al., 2017), number of children under five in the home, number of persons per room, and level of mother-child interaction(Santos et al., 2015), other parental and socioeconomic characteristics, (Pearson et al., 2019) age at the time of testing, family socioeconomic position, maternal parity, maternal smoking during pregnancy, child’s low birthweight, multiple pregnancies, maternal employment, and maternal psychiatric problems.(Matijasevich et al., 2014)

Mediators and Moderators

Two studies in Brazil examined mediators or moderators of the relationship between internalizing problems and their potential predictors. One study (Pearson et al., 2019) examined mediation of the relationship between the grandmother’s and child’s internalizing problems, finding partial mediation of mother internalizing problems. Another study examined the moderating role of verbal IQ in the relationship between early adversity and internalizing problems in early childhood and early adolescence (Corapci et al., 2006), finding that verbal IQ moderated this relationship in early adolescence but not in early childhood.

Differences by Sex and Age of Preschoolers

Differences by sex and age in scores of internalizing syndromes were explored in four studies. A study in Brazil(Matijasevich et al., 2014) found that girls had higher scores of anxiety/depression than boys and an increase in number of somatic complaints over the course of ten years. In Mexico, a study(Albores-Gallo et al., 2016) found that the scores for somatic complaints had higher internal consistency for boys than for girls. Studies in Argentina and Peru found no significant differences by sex in behavioral inhibition (Lacunza, 2011) or anxiety/withdrawn syndrome (based on the SCBE)(Bárrig Jó & Alarcón Parco, 2017).

Studies on the Measurement of Internalizing Problems

Three studies in the Americas examined the validity of the tests used to measure internalizing problems. A study in Mexico(Albores-Gallo et al., 2016) using the CBCL 1.5-5, concluded that anxiety and depression had better consistency when grouped. A study in Colombia (Cano et al., 2018) examined the criterion validity of the Early Childhood Screening Assessment, concluding that internalizing and externalizing symptoms load on more than one factor. A study in Argentina(Reyna & Brussino, 2009) examined the psychometric properties of the Preschool and Kindergarten Behavior Scales, finding that behavioral problems were explained by two factors: internalization and externalization.

European Region

All ten studies were written in English. Turkey had the highest number of studies in this region (four, or 40% of the studies). Regarding study type, seven were cross-sectional, two were longitudinal, and one was a randomized control trial. None of the cross-sectional studies (Hesapcioglu et al., 2017) had samples of fewer than 100 people. The studies in this region with samples smaller than that were longitudinal. The quality of the majority of studies was good (60%).

Prevalence of Internalizing Problems and Syndromes in the region

One study(Markovic et al., 2016), conducted in Serbia, estimated the prevalence (17%) of internalizing problems in a representative sample of preschoolers in one city. One study in Turkey(Erol et al., 2005) estimated the prevalence of behavioral problems at 11.9%, but the estimate for internalizing problems could not be teased out. A study in Romania reported that internalizing disorders were the most prevalent psychiatric disorders in preschool children(Zeanah et al., 2009).

Only the study in Serbia described the prevalence of internalizing syndromes. They found that the most common internalizing symptom was withdrawal (9.3%), and the least common (2.4%) was somatic complaints. One study in Turkey (Karabekiroglu et al., 2009) estimated the mean score of internalizing problems in the CBCL 2–3 to be 6.85 (normal scores). A study conducted in 24 countries(Rescorla et al., 2011) found that Turkey was the second highest-scoring country on the anxious/depressed syndrome and the fourth or fifth highest on the other three internalizing syndromes. Romania and Turkey were among the six countries with the highest mean scores on total internalizing problems in preschoolers.

Risk factors studied in the European region

Studies in this region focused on the relationship of internalizing problems with characteristics of the environment and with adverse events, emphasizing the effects of maternal psychopathology.

The risk factors significantly associated with internalizing problems were: maternal psychological problems (Hesapcioglu et al., 2017; Ruchkin et al., 2008; Yurdusen et al., 2013), alcohol use during pregnancy(Ruchkin et al., 2008), prenatal smoking(Wasserman et al., 2001), early effortful control(Kozlova et al., 2019), lifetime lead exposure(Wasserman et al., 2001), family dysfunction (Ruchkin et al., 2008), compromised postnatal condition of the child(Ruchkin et al., 2008), effective emotion regulation strategies (Ştefan & Avram, 2017), attachment security(Ştefan & Avram, 2017), institutionalization(Zeanah et al., 2009), urban residence(Erol et al., 2005), mother’s rejection of home-making role (Yurdusen et al., 2013).

The harmful exposures mentioned above, e.g., maternal psychopathology, low effective emotional reactivity strategies, all had a positive association with internalizing problems.

Regarding other exposures, one study(Erol et al., 2005) found that children from urban areas obtained significantly higher scores on internalizing problems than children from suburban and rural residences. Another study(Zeanah et al., 2009) found that children removed from institutions and placed in foster families were less likely to have internalizing disorders than those who continued care as usual (22.0% versus 44.2%).

Assessment of Confounding

Of the ten selected studies, three reported an assessment of confounding and adjusted estimates(Ruchkin et al., 2008; Ştefan & Avram, 2017; Wasserman et al., 2001). The confounders were: child’s age(Ruchkin et al., 2008; Ştefan & Avram, 2017; Wasserman et al., 2001), child’s sex, ethnicity, language spoken at home, acceptance, and maternal education(Wasserman et al., 2001), SES(Ruchkin et al., 2008).

Mediators and Moderators

A cross-sectional study in Russia (Ruchkin et al., 2008) found that continued maternal/family dysfunction and compromised postnatal condition of the child mediate the effects that alcohol use during pregnancy and maternal psychopathology have on child internalizing symptoms. Another cross-sectional study in Romania(Ştefan & Avram, 2017) found that effective emotion regulation (problem-solving) in the child fully mediated the relationship between attachment security and internalizing problems.

Moderation by the sex of the child was examined in this region, as discussed below.

Differences by Sex and Age of Preschoolers

Half of the studies in this region examined differences in internalizing problems by sex.

Two studies, one in Serbia(Markovic et al., 2016) and another in the former Yugoslavia (Wasserman et al., 2001), examined differences in internalizing problems by sex. One of the studies(Markovic et al., 2016) compared the mean scores of boys and girls on internalizing CBCL syndromes in Serbia with the mean scores of boys and girls in the United States (US). Serbian girls had significantly higher scores on total internalizing problems than Serbian boys (2.2 vs. 1.8). In the Caregiver Teacher Report Form (CTRF), both Serbian boys and girls had significantly higher mean somatic complaints than boys and girls in the US (3.8 vs. 3.6, and 1.2 vs. 0.7)(Markovic et al., 2016). The study in the former Yugoslavia (Wasserman et al., 2001) found that the only statistically significant interaction with sex was for somatic problems, where scores for somatic problems in girls differed across maternal smoking status.

A study in Romania (Zeanah et al., 2009) examined children reared both in institutions and who had never been institutionalized. Boys had more internalizing symptoms than girls, regardless of institutionalization history. Also, unlike girls, the total number of psychiatric symptoms of institutionalized boys was not reduced after being placed in foster care.

A study (Karabekiroglu et al., 2009) in Turkey found that the mean total internalizing scores of boys and girls were not significantly different. Regarding syndromes, another study in Turkey (Erol et al., 2005) found that girls had higher scores than boys on the anxious/depressed score. These same two studies in Turkey examined differences in internalizing problems by age. One found no significant differences by age (Karabekiroglu et al., 2009). The other found that two and three-year-olds had more somatic complaints than older children.(Erol et al., 2005)

Studies on the Measurement of Internalizing Problems

One selected study (Karabekiroglu et al., 2009), conducted in Turkey, assessed the validity and reliability of a scale to measure internalizing and externalizing problems in preschoolers (The Brief Infant-Toddler Social and Emotional Assessment (Briggs-Gowan et al., 2004)). The total score of this scale is correlated with internalizing and externalizing scores in the CBCL, but does not differentiate between the two dimensions.

Western Pacific Region

According to the WHO, the Western Pacific Region includes some Asian countries. Only five studies from this region, all from China, were included. The five studies selected were published in English, and they were rated as being of good quality. Four of these studies were longitudinal measures, and only one was cross-sectional. One of the longitudinal studies(Liang et al., 2019) had a sample of fewer than 100 people.

Only one study(Liu et al., 2013) estimated the prevalence of internalizing problem scores, at 18%, obtained from a representative sample of preschoolers in the city of Jintan.

Risk factors studied in China

The risk factors in the studies conducted in China were: Parenting stress(Liu & Wang, 2015), environmental tobacco smoke exposure during pregnancy (ETS)(Liu et al., 2013), micronutrient deficiency(J. Liu et al., 2014), blood lead concentration (Jianghong Liu et al., 2014), and infant withdrawal(Liang et al., 2019). Except for parenting stress in fathers and ETS, these risk factors were significantly associated with internalizing problems in preschoolers in the expected direction. For specific syndromes, an increase in blood lead concentration was associated with increased odds for anxious/depressed and emotionally reactive, as well as with increased odds for DSM oriented anxiety (J. Liu et al., 2014).

Assessment of Confounding

Four of the five selected studies reported adjusted estimates or assessments of confounding. The confounders were: child’s sex (J. Liu et al., 2014; Liu et al., 2013; Jianghong Liu et al., 2014), parental education(J. Liu et al., 2014; Liu et al., 2013; Jianghong Liu et al., 2014), occupation(Liu et al., 2013; Liu & Wang, 2015), school area (city, suburban or rural), and psychopathologic problems; maternal age during pregnancy; father’s current (postnatal) smoking status(Liu et al., 2013), family size, house size(J. Liu et al., 2014), residence, parents’ marital status, single child, IQ(Jianghong Liu et al., 2014), previous internalizing and externalizing problems(Liang et al., 2019).

Mediators and Moderators

Only one study (Liu & Wang, 2015) examined mediation. This study found that psychological aggression by mothers partially mediated the relationship between parenting stress and children’s internalizing behaviors. No significant direct effects or indirect effects of aggression by fathers were found though they were explored.

Differences by Sex and Age

One study examined sex and age differences. In boys, there was a slight negative association between blood lead concentration and internalizing problems at age 4. At age 5, blood lead concentration and internalizing problems were positively associated in both boys and girls. There were no studies in China on the measurement of Internalizing Problems identified in this review.

African Region

For this region, only one study conducted in South Africa (Rotheram-Fuller et al., 2018) met inclusion criteria. The study had good quality based on the PRISMA checklist. The study was a randomized controlled trial to examine the effect of an intervention on maternal depression during pregnancy and described the consequences of maternal depression on children’s problem behaviors in the first three years of life. They examined differences in direct symptom scores and differences in clinically significant scores (internalizing score deviant). Regarding symptom scores, children of mothers who had been depressed postnatally, antenatally, or both, had higher mean scores than chidlren of never depressed mothers. On the measure of internalizing score deviant, children of mothers who had been depressed postnatally, antenatally, or both, had a higher probability of symptoms than children of never depressed mothers.

Confounders

The confounders included in this study were maternal HIV status, alcohol use, food insecurity, and baseline education.

This systematic review provides further evidence that research on internalizing problems in preschoolers is scarce in LMICs. Despite the restrictive filters, more than 250 studies in the search were conducted in HICs. Therefore, including languages other than English in the search criteria provides a richer understanding of internalizing problems in preschoolers worldwide. By extending our search to Portuguese and Spanish, we were able to better characterize the internalizing problems of preschoolers in LMICs in the Americas. Still, our review fell short in all the other regions of the world, in particular the Eastern Mediterranean and the Southeast Asian regions, where we could not include any studies.

Our findings highlight the need for more validation of scales of behavioral problems of preschoolers in LMICs. The lack of valid instruments raises questions about the accuracy of the measurements. A common limitation in LMICs is best described as a vicious cycle: the lack of a valid scale that serves as a standard in a population complicates validation efforts, leading to a lack of valid scales. In our search, we only found four validation studies of behavioral problem scales in preschoolers, which were of moderate quality (three in the Americas(Albores-Gallo et al., 2016; Cano et al., 2018; Reyna & Brussino, 2009), and one in Europe (Karabekiroglu et al., 2009)). We only found validation studies of the CBCL in China, Peru, Turkey, Kosovo(Ivanova et al., 2010), and Mexico (Albores-Gallo et al., 2016). We do not know if the internalizing problems in any two given LMICs are comparable or if they refer to the same constructs (e.g., posttraumatic stress could be part of the internalizing problems), or if the syndromes have a different meaning when applied to different geographic or cultural groups of preschoolers (e.g., boys and girls, rural and urban). However, our findings suggest that due to the high comorbidity of the symptoms of internalizing and externalizing problems, both should always be reported separately and in total in studies of child behavior.

The studies with small samples or of poor quality may provide inaccurate results or may not provide the full background of the predictors of internalizing symptoms in each country. However they identify relevant variables to explore, such as sleep disturbance(El Rafihi-Ferreira et al., 2016), mother and child emotional availability (Gil Rodríguez et al., 2018), and verbal IQ(Corapci et al., 2006), as well as provide plausible hypotheses that could be tested in larger samples in which a larger number of variables are evaluated. The Americas was the region with the highest proportion of studies with small samples (ranging from 20 to 92 participants). This could be due to prioritizing more life-threatening conditions and due to the countries in the region having fewer resources to fund studies at a larger scale, or may be due to publication bias, in that studies in English internationally from LMICs might be larger and of possibly of higher quality than those published in local languages. Brazil, the country with the most articles in our sample, was an outlier; most studies in this country were of good quality, had large samples and a longitudinal design. The increased attention to this topic in Brazil could be due to efforts to reduce the alarmingly elevated rates of anxiety and depression (first and fifth highest worldwide) and related disability in people aged 15 years and older (Organization, 2017), and also more robust financial support than the rest of Latin America (Gutiérrez & Landeira-Fernández, 2018) and high internationalization of Brazilian scientific output (Fradkin, 2017).

Since the most reliable data in the region of the Americas comes from Brazil, most of the results discussed were from Brazilian studies, and most of our conclusions on internalizing problems apply mainly to this country. To a lesser extent, they could apply to other LMICs in the region. However, we found commonalities across this region regarding risk factors. This region focused on examining risk factors related to the children and the home environment, emphasizing on maternal characteristics, which strengthened the evidence on the strong influence that parents and the environment can have on child mental health. However, there was not a marked interest in studying parental psychopathology, one of the main predictors of child internalizing problems, as seen in studies in the European region.

The European region had a larger percentage of good quality studies (60%) than the Americas. Turkey, the European country with most studies included, also has high adolescence and adult rates of anxiety (four points above world average), depression, and related disability, and it is probable that, like Brazil, this investment in research on the topic is reflective of increasing efforts to reduce them.

In European studies, there were frequent descriptions of the number of children who had clinically significant problems, providing a context for the scores. For example, an increase in a score could still mean low risk but having the proportion of clinically significant cases allows us to identify if there is an incidence increase, understand the magnitude of the problem, and explore potential causes, to inform prevention and treatment efforts.

Also, in the European region, there was a focus on examining differences by sex of the child. Boys and girls did not appear to have significantly different scores on internalizing problems, but they had significant differences in the pattern of syndromes (e.g., girls have more anxious/depressed scores than boys, boys have more somatic complaints scores than girls). This coincides with findings in the region of the Americas. These results warrant further examination of the structure of internalizing problems of boys’ and girls to identify targets of treatment and understand if preschool-age boys and girls experience internalizing problems differently.

Another important finding in one study in the European region is that lead exposure was significantly and positively associated with increased internalizing problems in preschoolers (Daniel Fatori et al., 2019). This coincides with findings from a Chinese study(Liu et al., 2013), where blood lead was associated with higher scores on anxiety/depression, emotional reactivity, and pervasive developmental problems. The study, along with two more studies in China, shows an interest in the effect that harmful environmental substances and lack of micronutrients can have on internalizing problems. The direct effect of harmful substances should be further explored in other regions to understand better all the risk factors that could lead to internalizing problems in preschoolers.

China was the only LMIC in the Western Pacific WHO region where studies met inclusion criteria in this review. The five studies in the sample were all of good quality, with large samples and longitudinal designs. Compared with other regions, Chinese studies provided more mean estimates broken down by syndrome (withdrawn, anxiety/depression, somatic complaints, emotional reactivity). There were also more examinations of the relationships of each syndrome with the risk factors than in other regions. This approach serves as a basis for more thorough explanations of the development pathways of internalizing problems in preschoolers.

The study selected from the African region was conducted in South Africa (Rotheram-Fuller et al., 2018). Their findings on the effects of maternal psychopathology in internalizing problems in their offspring(Hammen et al., 2012; Klasen et al., 2015; Rasic et al., 2014)agreed with several other studies included in this review. A single study does not allow us to draw conclusions applicable to the country, and even less to the region. There could be additional studies published in country official local languages, but the review criteria excluded all not published in English, Spanish or Portuguese.

Perhaps the main limitation of our study was the inability to include studies in different languages to provide a broader picture of internalizing problems in LMICs. Future research on the topic should aim to expand such a review to other frequently widely spoken languages such as Chinese Mandarin, French, and Arabic. Overall, all relationships between variables were in the expected direction, that is, adverse exposures had a positive association with internalizing problems, and beneficial exposures had a negative association with internalizing problems. Most of the studies in the European region and China focused on testing specific hypotheses regarding the relationships between variables. In contrast, most studies in the region of the Americas had an exploratory approach, mainly due to the small samples and lack of comparison groups.

Future studies, if possible, should include data on the clinically significant cases of internalizing and externalizing problems as well as reporting on symptoms. This would provide context to the results that an increase in mean scores of total internalizing problems does not, as such an increase could be statistically significant, but clinically irrelevant. An increase in the number of clinically significant cases due to a particular risk factor, such as lead or maternal depression, could warrant attention that could lead to identification of intervention targets. Our findings provide a basis for future research on behavioral problems in preschoolers and helps inform decisions on young children's mental health in LMICs.

Acknowledgements

Authors would like to thank Doctor George Musa at Columbia University for his input during the dissertation that is the source of this manuscript.

Financial Support

Doctor Maldonado Martinez received funding from Colciencias and Icetex for her dissertation that is the basis of this research.

Author Contribution statement

Adriana Maldonado Martinez (conceptualization, research, methodology, project administration, formal analysis, writing original draft and review and editing) , Sheila C Caetano (conceptualization, review and editing) , Leslie L Davidson (conceptualization, review and editing), Débora Muszkat Salviani (investigation, data curation, review and editing) , Luis M Silva (supervision, review and editing), Jose L Wilches-Gutierrez (review and editing), Pamela J. Surkan (review and editing), Silvia S Martins (conceptualization, supervision, writing original draft, review and editing).

Conflict of Interest statement

Adriana Maldonado Martinez , Sheila C Caetano, Leslie L Davidson, Débora Muszkat Salviani , Luis M Silva, Jose L Wilches-Gutierrez, Pamela J. Surkan, Silvia S Martins declare that they have no conflicts of interest.

Data Availability statement

The authors confirm that the data supporting the findings of this study are available within the references cited in the article.

Achenbach, T. M., & Rescorla, L. A. (2000). Manual for the ASEBA preschool forms and profiles (Vol. 30). Burlington, VT: University of Vermont, Research center for children, youth ….
Albores-Gallo, L., Hernández-Guzmán, L., Hasfura-Buenaga, C., & Navarro-Luna, E. (2016). Consistencia interna y validez de criterio de la versión mexicana del Child Behavior Checklist 1.5-5 (CBCL/1.5-5). Revista Chilena de Pediatría, 87(6), 455-462. https://doi.org/https://doi.org/10.1016/j.rchipe.2016.05.009
Ali, G.-C., Ryan, G., & De Silva, M. J. (2016). Validated screening tools for common mental disorders in low and middle income countries: a systematic review. PloS one, 11(6).
Ashford, J., Smit, F., Van Lier, P. A., Cuijpers, P., & Koot, H. M. (2008). Early risk indicators of internalizing problems in late childhood: a 9‐year longitudinal study. Journal of Child Psychology and Psychiatry, 49(7), 774-780.
Bárrig Jó, P., & Alarcón Parco, D. (2017). Temperamento y competencia social en niños y niñas preescolares de San Juan de Lurigancho: un estudio preliminar. Temperament and social competence in preschool children from San Juan de Lurigancho: a preliminary study., 23(1), 75-88. https://doi.org/10.24265/liberabit.2017.v23n1.05
Bifulco, A., Moran, P. M., Ball, C., Jacobs, C., Baines, R., Bunn, A., & Cavagin, J. (2002). Childhood adversity, parental vulnerability and disorder: examining inter-generational transmission of risk. J Child Psychol Psychiatry, 43(8), 1075-1086.
Briggs-Gowan, M. J., Carter, A. S., Irwin, J. R., Wachtel, K., & Cicchetti, D. V. (2004). The Brief Infant-Toddler Social and Emotional Assessment: screening for social-emotional problems and delays in competence. Journal of pediatric psychology, 29(2), 143-155.
Burke, H. M., Davis, M. C., Otte, C., & Mohr, D. C. (2005). Depression and cortisol responses to psychological stress: a meta-analysis. Psychoneuroendocrinology, 30(9), 846-856.
Cano, L. H., Acosta, M. N., & Pulido, A. (2018). Adaptación al español y validación de criterio de una escala para la tamización de problemas emocionales y del comportamiento en la primera infancia. Adaptation to Spanish and criterion validity of a scale for the screening of emotional and behavioral problems in early childhood., 1-1. https://doi.org/10.7705/biomedica.v38i0.3795
Caspi, A., Houts, R. M., Belsky, D. W., Goldman-Mellor, S. J., Harrington, H., Israel, S., Meier, M. H., Ramrakha, S., Shalev, I., & Poulton, R. (2014). The p factor: one general psychopathology factor in the structure of psychiatric disorders? Clinical Psychological Science, 2(2), 119-137.
Chioda, L. (2017). Stop the violence in Latin America: a look at prevention from cradle to adulthood. The World Bank.
Contributors, W. (2019). List of countries by income equality. Wikipedia, the Free Encyclopedia. https://en.wikipedia.org/w/index.php?title=List_of_countries_by_income_equality&oldid=897231253
Corapci, F., Smith, J., & Lozoff, B. (2006). The role of verbal competence and multiple risk on the internalizing behavior problems of Costa Rican youth. Ann N Y Acad Sci, 1094, 278-281. https://doi.org/10.1196/annals.1376.034
Cruz, J. M. (2016). State and criminal violence in Latin America. Crime, Law and Social Change, 66(4), 375-396.
Daniel Fatori, Ph.D. ,, Giovanni Abrahão Salum, M.D., Ph.D. ,, Luis Augusto Rohde, M.D., Ph.D. ,, Pedro Mario Pan, M.D., Ph.D. ,, Rodrigo Bressan, M.D., Ph.D. ,, Sara Evans-Lacko, Ph.D. ,, Guilherme Polanczyk, M.D., Ph.D. ,, Euripedes Constantino Miguel, M.D., Ph.D. ,, & Ana Soledade Graeff-Martins, M.D., Ph.D. (2019). Use of Mental Health Services by Children With Mental Disorders in Two Major Cities in Brazil. Psychiatric Services, 70(4), 337-341. https://doi.org/10.1176/appi.ps.201800389
Denham, S. A. (1998). Emotional development in young children. Guilford Press.
Docherty, M., Shaw, K., Goulding, L., Parke, H., Eassom, E., Ali, F., & Thornicroft, G. (2017). Evidence-based guideline implementation in low and middle income countries: lessons for mental health care. International journal of mental health systems, 11(1), 8.
El Rafihi-Ferreira, R., Ferreira de Mattos Silvares, E., Pires, M. L. N., Assumpção, F. B., Jr., & de Moura, C. B. (2016). Sono e comportamento em crianças atendidas em um Serviço de psicologia = Sleep and behavior in children assisted in a psychology service. Psicologia: Teoria e Prática, 18(2), 159-172. https://doi.org/10.15348/1980-6906/psicologia.v18n2p159-172
Erol, N., Simsek, Z., Oner, O., & Munir, K. (2005). Behavioral and emotional problems among Turkish children at ages 2 to 3 years. J Am Acad Child Adolesc Psychiatry, 44(1), 80-87. https://doi.org/10.1097/01.chi.0000145234.18056.82
Foland-Ross, L. C., Behzadian, N., LeMoult, J., & Gotlib, I. H. (2016). Concordant Patterns of Brain Structure in Mothers with Recurrent Depression and Their Never-Depressed Daughters. Dev Neurosci, 38(2), 115-123. https://doi.org/10.1159/000444448
Fradkin, C. (2017). La Internacionalización de las Revistas de Psicología en Brasil: Un Examen Bibliométrico Basado en Cuatro Índices. Paidéia (Ribeirão Preto), 27(66), 7-15.
Gil Rodríguez, L., Lucio Gómez Maqueo, E., & Forns i Santacana, M. (2018). Patrones de disponibilidad emocional y los problemas de salud mental del pre-escolar. Acta de investigación psicológica, 8(1), 37-48. https://doi.org/10.22201/fpsi.20074719e.2018.1.04
Giménez, G. (2016). Violence and growth in Latin America.
Gonzálvez, C., Kearney, C. A., Jiménez-Ayala, C. E., Sanmartín, R., Vicent, M., Inglés, C. J., & García-Fernández, J. M. J. P. r. (2018). Functional profiles of school refusal behavior and their relationship with depression, anxiety, and stress. 269, 140-144.
Groh, A. M., Roisman, G. I., van IJzendoorn, M. H., Bakermans‐Kranenburg, M. J., & Fearon, R. P. (2012). The significance of insecure and disorganized attachment for children’s internalizing symptoms: A meta‐analytic study. Child development, 83(2), 591-610.
Gutiérrez, G., & Landeira-Fernández, J. (2018). Psychological Research in Latin America: Current and Future Perspectives. In R. Ardila (Ed.), Psychology in Latin America: Current Status, Challenges and Perspectives (pp. 7-26). Springer International Publishing. https://doi.org/10.1007/978-3-319-93569-0_2
Hammen, C., Hazel, N. A., Brennan, P. A., & Najman, J. (2012). Intergenerational Transmission and Continuity of Stress and Depression: Depressed Women and their Offspring in 20 Years of Follow-up. Psychological medicine, 42(5), 931-942. https://doi.org/10.1017/S0033291711001978
Hesapcioglu, S. T., Ceylan, M. F., Erdogan, B., Kandemir, G., & Cop, E. (2017). Which psychiatric symptoms of the mother are related with preschool child’s emotional and behavioral problems? Düşünen Adam: Journal of Psychiatry and Neurological Sciences, 30(1), 6-14. https://doi.org/10.5350/DAJPN2017300101
Hillis, S., Mercy, J., Amobi, A., & Kress, H. (2016). Global prevalence of past-year violence against children: a systematic review and minimum estimates. Pediatrics, 137(3), e20154079.
Innovation, V. H. (2018). Covidence systematic review software. In www.covidence.org
Ivanova, M. Y., Achenbach, T. M., Rescorla, L. A., Harder, V. S., Ang, R. P., Bilenberg, N., Bjarnadottir, G., Capron, C., De Pauw, S. S., & Dias, P. (2010). Preschool psychopathology reported by parents in 23 societies: testing the seven-syndrome model of the child behavior checklist for ages 1.5–5. Journal of the American Academy of Child & Adolescent Psychiatry, 49(12), 1215-1224.
Karabekiroglu, K., Rodopman-Arman, A., Ay, P., Ozkesen, M., Akbas, S., Tasdemir, G. N., Boke, O., & Peksen, Y. (2009). The reliability and validity of the Turkish version of the brief infant-toddler social emotional assessment (BITSEA). Infant Behav Dev, 32(3), 291-297. http://dx.doi.org/10.1016/j.infbeh.2009.03.003
Kashani, J. H., Horwitz, E., Ray, J. S., & Reid, J. C. (1986). DSM-III diagnostic classification of 100 preschoolers in a child development unit. Child psychiatry and human development, 16(3), 137-147.
Keenan, K., Shaw, D., Delliquadri, E., Giovannelli, J., & Walsh, B. (1998). Evidence for the continuity of early problem behaviors: application of a developmental model. J Abnorm Child Psychol, 26(6), 441-452. https://doi.org/10.1023/a:1022647717926
Klasen, F., Otto, C., Kriston, L., Patalay, P., Schlack, R., Ravens-Sieberer, U., & Group, B. S. (2015). Risk and protective factors for the development of depressive symptoms in children and adolescents: results of the longitudinal BELLA study. European child & adolescent psychiatry, 24(6), 695-703.
Kopala-Sibley, D. C., & Klein, D. N. (2017). Distinguishing types of social withdrawal in children: Internalizing and externalizing outcomes of conflicted shyness versus social disinterest across childhood. Journal of research in personality, 67, 27-35.
Kozlova, E. A., Slobodskaya, H. R., & Gartstein, M. A. (2019). Early temperament as a predictor of child mental health. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-019-00181-3
Krishnan, V., & Nestler, E. J. (2008). The molecular neurobiology of depression. Nature, 455(7215), 894-902. https://doi.org/10.1038/nature07455
Lacunza, A. B. (2011). Habilidades sociales y comportamientos problemáticos en niños de nivel escolar inicial = Social skills and problematic behaviour in pre-school children. Acta Psiquiátrica y Psicológica de América Latina, 57(3), 190-197. https://ezproxy.cul.columbia.edu/login?qurl=https%3a%2f%2fsearch.ebscohost.com%2flogin.aspx%3fdirect%3dtrue%26db%3dpsyh%26AN%3d2011-23710-002%26site%3dehost-live%26scope%3dsite
Lansford, J. E., Deater-Deckard, K., Bornstein, M. H., Putnick, D. L., & Bradley, R. H. (2014). Attitudes justifying domestic violence predict endorsement of corporal punishment and physical and psychological aggression towards children: a study in 25 low-and middle-income countries. The Journal of pediatrics, 164(5), 1208-1213.
Liang, X., Liu, M., Wang, M., Yu, J., Wang, Z., & Lu, S. (2019). Infant withdrawal and behavior problems in urban Chinese toddlers: Roles of maternal sensitivity to infant distress and emerging delay ability. Infant Mental Health Journal, 40(2), 248-262. https://doi.org/10.1002/imhj.21763
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P., Clarke, M., Devereaux, P. J., Kleijnen, J., & Moher, D. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Annals of internal medicine, 151(4), W-65-W-94.
Lins, T., & Alvarenga, P. (2015). Controle Psicológico Materno e Problemas Internalizantes em Pré-Escolares = Maternal psychological control and internalizing problems of preschool children. Psicologia: Teoria e Pesquisa, 31(3), 311-319. https://doi.org/10.1590/0102-37722015032092311319
Liu, J., Hanlon, A., Ma, C., Zhao, S. R., Cao, S., & Compher, C. (2014). Low blood zinc, iron, and other sociodemographic factors associated with behavior problems in preschoolers. Nutrients, 6(2), 530-545. https://doi.org/10.3390/nu6020530
Liu, J., Leung, P. W. L., McCauley, L., Ai, Y., & Pinto-Martin, J. (2013). Mother's environmental tobacco smoke exposure during pregnancy and externalizing behavior problems in children. Neurotoxicology, 34, 167-174. http://dx.doi.org/10.1016/j.neuro.2012.11.005
Liu, J., Liu, X., Wang, W., McCauley, L., Pinto-Martin, J., Wang, Y., Li, L., Yan, C., & Rogan, W. J. (2014). Blood lead concentrations and children's behavioral and emotional problems: a cohort study. JAMA Pediatr, 168(8), 737-745. http://dx.doi.org/10.1001/jamapediatrics.2014.332
Liu, L., & Wang, M. (2015). Parenting stress and children's problem behavior in China: the mediating role of parental psychological aggression. J Fam Psychol, 29(1), 20-28. https://doi.org/10.1037/fam0000047
Markovic, J., Rescorla, L., Okanovic, P., Maras, J. S., Bukurov, K. G., & Sekulic, S. (2016). Assessment of preschool psychopathology in Serbia. Res Dev Disabil, 49-50, 216-225. https://doi.org/10.1016/j.ridd.2015.11.027
Martel, M. M., Pan, P. M., Hoffmann, M. S., Gadelha, A., do Rosário, M. C., Mari, J. J., Manfro, G. G., Miguel, E. C., Paus, T., & Bressan, R. A. (2017). A general psychopathology factor (P factor) in children: structural model analysis and external validation through familial risk and child global executive function. Journal of Abnormal Psychology, 126(1), 137.
Matijasevich, A., Murray, E., Stein, A., Anselmi, L., Menezes, A. M., Santos, I. S., Barros, A. J., Gigante, D. P., Barros, F. C., & Victora, C. G. (2014). Increase in child behavior problems among urban Brazilian 4-year olds: 1993 and 2004 Pelotas birth cohorts. J Child Psychol Psychiatry, 55(10), 1125-1134. https://doi.org/10.1111/jcpp.12236
McDaid, D., Knapp, M., & Raja, S. (2008). Barriers in the mind: promoting an economic case for mental health in low‐and middle‐income countries. World Psychiatry, 7(2), 79-86.
Montoya Arenas, D. A., Vásquez, N. G., Arango Díaz, L., Forgiarini Rupp, R., & García Cardona, A. A. (2014). CARACTERÍSTICAS COGNITIVAS, EMOCIONALES Y CONDUCTUALES DE NIÑOS PREESCOLARES DEL PROGRAMA BUEN COMIENZO EN EL NOROCCIDENTE DE MEDELLÍN. COGNITIVE, EMOTIONAL, AND BEHAVIORAL CHARACTERISTICS OF PRESCHOOLERS OF THE GOOD START PROGRAM IN THE NORTHWESTERN AREA IN MEDELLIN., 14(2), 637-645. https://doi.org/10.21500/16578031.38
Morales, A., & Wang, K. T. J. J. o. M. H. C. (2018). The relationship among language brokering, parent–child bonding, and mental health correlates among Latinx college students. 40(4), 316-327.
Muggah, R., & Tobón, K. A. (2018). Citizen security in Latin America: Facts and Figures. Strategic paper, 33.
Murray, L., Creswell, C., & Cooper, P. (2009). The development of anxiety disorders in childhood: An integrative review (Vol. 39). https://doi.org/10.1017/S0033291709005157
National Heart, L., & Institute, B. (2014). Quality assessment tool for observational cohort and cross-sectional studies. Bethesda: National Institutes of Health, Department of Health and Human Services, 103-111.
Neumann, I. D., & Landgraf, R. (2012). Balance of brain oxytocin and vasopressin: implications for anxiety, depression, and social behaviors. Trends in neurosciences, 35(11), 649-659.
NIMH. (2017, November 2017). Persistent Depressive Disorder (Dysthymic Disorder). National Institute of Mental Health. Retrieved July 16, 2018 from https://www.nimh.nih.gov/health/statistics/persistent-depressive-disorder-dysthymic-disorder.shtml#part_155912
Norman, R. E., Byambaa, M., De, R., Butchart, A., Scott, J., & Vos, T. (2012). The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS medicine, 9(11), e1001349.
Organization, W. H. (2017). Depression and other common mental disorders: global health estimates.
Pearson, R. M., Culpin, I., Loret de Mola, C., Matijasevich, A., Santos, I. S., Horta, B. L., Barros, F. C., & Stein, A. (2019). Grandmothers’ mental health is associated with grandchildren’s emotional and behavioral development: A three-generation prospective study in Brazil. BMC Psychiatry, 19. https://ezproxy.cul.columbia.edu/login?qurl=https%3a%2f%2fsearch.ebscohost.com%2flogin.aspx%3fdirect%3dtrue%26db%3dpsyh%26AN%3d2019-34500-001%26site%3dehost-live%26scope%3dsite
Rasic, D., Hajek, T., Alda, M., & Uher, R. (2014). Risk of Mental Illness in Offspring of Parents With Schizophrenia, Bipolar Disorder, and Major Depressive Disorder: A Meta-Analysis of Family High-Risk Studies. Schizophrenia Bulletin, 40(1), 28-38. https://doi.org/10.1093/schbul/sbt114
Rathod, S., Pinninti, N., Irfan, M., Gorczynski, P., Rathod, P., Gega, L., & Naeem, F. (2017). Mental health service provision in low-and middle-income countries. Health services insights, 10, 1178632917694350.
Razzouk, D., Sharan, P., Gallo, C., Gureje, O., Lamberte, E. E., de Jesus Mari, J., Mazzotti, G., Patel, V., Swartz, L., & Olifson, S. (2010). Scarcity and inequity of mental health research resources in low-and-middle income countries: a global survey. Health Policy, 94(3), 211-220.
Rescorla, L. A., Achenbach, T. M., Ivanova, M. Y., Harder, V. S., Otten, L., Bilenberg, N., Bjarnadottir, G., Capron, C., De Pauw, S. S. W., Dias, P., Dobrean, A., Döpfner, M., Duyme, M., Eapen, V., Erol, N., Esmaeili, E. M., Ezpeleta, L., Frigerio, A., Fung, D. S. S., . . . Verhulst, F. C. (2011). International comparisons of behavioral and emotional problems in preschool children: Parents' reports from 24 societies. Journal of Clinical Child and Adolescent Psychology, 40(3), 456-467. https://doi.org/10.1080/15374416.2011.563472
Reyna, C., & Brussino, S. (2009). Propiedades Psicométricas de la Escala de Comportamiento Preescolar y Jardín Infantil en una Muestra de Niños Argentinos de 3 a 7 Años. Psychometric Properties of the Preschool and Kindergarten Behavior Scales in a Sample of Argentinean Children from 3 to 7 Years Old., 18(2), 127-140. https://doi.org/10.4067/S0718-22282009000200009
Rivera, M. (2016). The sources of social violence in Latin America: An empirical analysis of homicide rates, 1980–2010. Journal of Peace Research, 53(1), 84-99.
Rotheram-Fuller, E. J., Tomlinson, M., Scheffler, A., Weichle, T. W., Hayati Rezvan, P., Comulada, W. S., & Rotheram-Borus, M. J. (2018). Maternal patterns of antenatal and postnatal depressed mood and the impact on child health at 3-years postpartum. J Consult Clin Psychol, 86(3), 218-230. https://doi.org/10.1037/ccp0000281
Ruchkin, V., Gilliam, W. S., & Mayes, L. (2008). Developmental pathway modeling in considering behavior problems in young Russian children. Child Psychiatry Hum Dev, 39(1), 49-66. https://doi.org/10.1007/s10578-007-0070-9
Santos, I. S., Barros, A. J., Barros, F. C., Munhoz, T. N., Da Silva, B. D. P., & Matijasevich, A. (2017). Mother-child bed-sharing trajectories and psychiatric disorders at the age of 6 years. J Affect Disord, 208, 163-169. https://doi.org/10.1016/j.jad.2016.08.054
Santos, L. M. d., Queirós, F. C., Barreto, M. L., & Santos, D. N. d. (2015). Prevalence of behavior problems and associated factors in preschool children from the city of Salvador, state of Bahia, Brazil. Brazilian Journal of Psychiatry, 38(1), 46-52. https://doi.org/10.1590/1516-4446-2014-1596
Semrau, M., Evans-Lacko, S., Koschorke, M., Ashenafi, L., & Thornicroft, G. (2015). Stigma and discrimination related to mental illness in low-and middle-income countries. Epidemiology and psychiatric sciences, 24(5), 382-394.
Slemming, K., Sørensen, M. J., Thomsen, P. H., Obel, C., Henriksen, T. B., & Linnet, K. M. (2010). The association between preschool behavioural problems and internalizing difficulties at age 10–12 years. European child & adolescent psychiatry, 19(10), 787-795.
Starr, L. R., Conway, C. C., Hammen, C., & Brennan, P. A. (2014). Transdiagnostic and disorder-specific models of intergenerational transmission of internalizing pathology. Psychological medicine, 44(1), 161-172.
Ştefan, C. A., & Avram, J. (2017). Investigating direct and indirect effects of attachment on internalizing and externalizing problems through emotion regulation in a cross-sectional study. Journal of Child and Family Studies, 26(8), 2311-2323. https://doi.org/10.1007/s10826-017-0723-7
Sterba, S. K., Prinstein, M. J., & Cox, M. J. (2007). Trajectories of internalizing problems across childhood: Heterogeneity, external validity, and gender differences. Development and psychopathology, 19(2), 345-366.
Tandon, M., Cardeli, E., & Luby, J. (2009). Internalizing disorders in early childhood: a review of depressive and anxiety disorders. Child and adolescent psychiatric clinics of North America, 18(3), 593-610. https://doi.org/10.1016/j.chc.2009.03.004
Vigo, D., Thornicroft, G., & Atun, R. (2016). Estimating the true global burden of mental illness. The Lancet Psychiatry, 3(2), 171-178.
Vos, T., Allen, C., Arora, M., Barber, R. M., Bhutta, Z. A., Brown, A., Carter, A., Casey, D. C., Charlson, F. J., & Chen, A. Z. (2016). Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet, 388(10053), 1545-1602.
Wainberg, M. L., Scorza, P., Shultz, J. M., Helpman, L., Mootz, J. J., Johnson, K. A., Neria, Y., Bradford, J.-M. E., Oquendo, M. A., & Arbuckle, M. R. (2017). Challenges and Opportunities in Global Mental Health: a Research-to-Practice Perspective. Current psychiatry reports, 19(5), 28-28. https://doi.org/10.1007/s11920-017-0780-z
Wasserman, G. A., Liu, X., Pine, D. S., & Graziano, J. H. (2001). Contribution of maternal smoking during pregnancy and lead exposure to early child behavior problems. Neurotoxicology and Teratology, 23(1), 13-21. https://doi.org/10.1016/S0892-0362(00)00116-1
Yurdusen, S., Erol, N., & Gençöz, T. (2013). The effects of parental attitudes and mothers' psychological well-being on the emotional and behavioral problems of their preschool children. Matern Child Health J, 17(1), 68-75. http://dx.doi.org/10.1007/s10995-012-0946-6
Zeanah, C. H., Egger, H. L., Smyke, A. T., Nelson, C. A., Fox, N. A., Marshall, P. J., & Guthrie, D. (2009). Institutional rearing and psychiatric disorders in Romanian preschool children. The American Journal of Psychiatry, 166(7), 777-785. https://doi.org/10.1176/appi.ajp.2009.08091438

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Description of Included Studies by Region

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Anxiety, depression and other internalizing problems of young children in low and middle-income countries before the covid-19 pandemic

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Abstract

Figures

Impact statement

Introduction

Methods

Results

General Characteristics of the Studies

Region of the Americas

Prevalence of Internalizing problems and syndromes in the region

Risk factors studied in the region of the Americas

Assessment of Confounding

Mediators and Moderators

Differences by Sex and Age of Preschoolers

Studies on the Measurement of Internalizing Problems

European Region

Prevalence of Internalizing Problems and Syndromes in the region

Risk factors studied in the European region

Assessment of Confounding

Mediators and Moderators

Differences by Sex and Age of Preschoolers

Studies on the Measurement of Internalizing Problems

Western Pacific Region

Risk factors studied in China

Assessment of Confounding

Mediators and Moderators

Differences by Sex and Age

African Region

Confounders

Discussion

Declarations

References

Appendix

Additional Declarations

Supplementary Files

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