Gender, age, and cultural differences in the Japanese version of the Infant-Toddler Social and Emotional Assessment

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1 J Med Dent Sci 215; 62: Original Article Gender, age, and cultural differences in the Japanese version of the Infant-Toddler Social and Emotional Assessment Satoshi Yago 1), Taiko Hirose 1), Aki Kawamura 2), Takahide Omori 3) and Motoko Okamitsu 1) 1) Tokyo Medical and Dental University 2) Shukutoku University 3) Keio University This study aimed to clarify the characteristics of the Japanese version of the Infant-Toddler Social and Emotional Assessment (J-), a parentreport questionnaire concerning social-emotional/ behavioral problems and delays in competence in 1- to 3-year-old children. The differences in score between genders, ages, and between the J- and the original Infant-Toddler Social and Emotional Assessment were examined. The data of 617 participants recruited from Saitama prefecture through stratified two-stage sampling were analyzed. The Cronbach s alpha ranged from.76 to.93. Gender differences emerged for some problems and all competence scales, with boys rated higher in the Externalizing problem domain and Activity/Impulsivity subscale and girls rated higher in the Internalizing problem domain, Inhibition to Novelty subscale, and all Competence scales. The Competence domain score increased across age groups. Compared with a normative sample in the US, participants in this study rated higher in Aggression/Defiance and Separation Distress, and rated lower in Peer Aggression and most of the Competence scales. The results indicate that the J- scores should be interpreted in comparison with standard scores assigned for gender and 6-month age groups, and that specific criteria for the cut-off points for the J- are required Corresponding Author: Satoshi Yago, RN, MSN Section of Child and Family Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Yushima, Bunkyo-ku, Tokyo , Japan Tel: Fax: sycfn@tmd.ac.jp Received May 28;Accepted November 27, 215 instead of those in the original questionnaire. Key Words: infant behavior, social behavior, emotions, infant, psychometrics Introduction In recent years, the number of children with developmental disorders has been increasing 1, and the early detection and subsequent proper and adequate support for these children has become more important 2-4. These early signs of psychopathology may emerge in early childhood where psychosocial development progresses with remarkable speed 5. The prevalence of social-emotional and behavioral problems in preschool children has been reported to be 7% to 26% 6-1. These problems are not transient but are sustained to school age, and predict later psychopathology This evidence emphasizes that psychosocial problems should be detected at a very young age and followed with appropriate care. However, the diagnosis of developmental disorders in early childhood is unreliable 15, especially when the problems are not so conspicuous or when parents do not recognize the problems. In fact, it was reported that 8% to 9% of preschool children were found to have some developmental disabilities at the infant medical examination for 5-year-olds although no developmental abnormality had been detected at the 3-year-old examination 16. Many nurses, who play an important role in the early detection in the primary care setting and medical examinations, thought that it was not possible to detect those children due to lack of time and skill 17. Moreover, standardized assessment tools were not used effectively in the practice 17, 18. The

2 92 S. Yago et al. J Med Dent Sci failure of early detection and support for infants and toddlers with significant social-emotional and behavioral problems might exacerbate these problems, and cause secondary impairments, such as school refusal and social withdrawal, and even child abuse proceeding from their specific characteristic of being difficult to raise 19, 2. To address these problems, the development of a reliable and valid assessment tool is required that is standardized in a Japanese sample and provides a comprehensive picture of children s development that will aid clinical judgments. However, many of the instruments that are published in Japan and aim to measure social-emotional/behavioral problems cannot be applied to children less than 2-years-old, or they only focus on assessing problem behaviors or a single psychopathology, such as autism spectrum disorders It is important for nurses to assess not only each child s behavioral problems but also his/her competencies that minimize the emergence and persistence of the behavioral problems as well as indicate a strength that may be a focal point of intervention 24. Such a tool will capture a whole picture of each child and enable individualized support. The Infant-Toddler Social and Emotional Assessment () is an assessment tool for infants and toddlers aged from 1- to 3-years-old that measures social-emotional/ behavioral problems as well as competencies 24. The was developed in the US based on comprehensive reviews of the developmental psychology and pediatric psychopathology literatures and diagnostic classifications 25, 26, and it has been reported to have acceptable reliability and validity 27, 28. The is designed to assess the presence of broad behavior problems and the delay/absence of competencies in very young children. The has been translated into several languages 29, 3 and is used in clinical and research settings. Kawamura 31 developed the Japanese version of the (J-) for childcare support and nursing in Japan, which shows good internal consistency (Cronbach s alpha from.7 to.93) and test-retest reliability (Spearman s rho from.51 to.91), and has expected concurrent validity with the Child Behavior Checklist 2/3 21 and Pervasive Developmental Disorders Autism Society Japan Rating Scale 32. To enhance the usability of the J- in the Japanese primary care setting, we need to establish the statistical criteria, such as mean score and standard deviation (SD), of the J- within a Japanese normative sample. The main purpose of the study was to examine differences in scores between children of different genders and ages and compare the J- and the original, to describe the characteristics of the J- in a standard sample. Exploring gender, age, and cultural differences could also provide useful information in developing norms for J- scores. The secondary purpose of the study was to explore an appropriate evaluation method for the J- in a Japanese clinical setting and establish the cut-off point for J- scores. Materials and Methods Participants Fifteen hundred children who were aged from 12 months to 35 months and 3 days, and whose parents were living in Saitama prefecture, were invited to participate in the study from April 1 to April 18, 214. Infants whose parents were not Japanese and who had severe congenital heart disease, brain malformation, or chromosomal abnormality were excluded. Setting Participants were recruited from the Basic Resident Register in Saitama prefecture. Saitama prefecture is part of the Greater Tokyo Area and located directly north of Tokyo. It consists of 72 municipalities, including densely populated big cities, smaller cities spread within the suburbs, and mountain regions. The social indicators of Saitama prefecture and that of the national average are as follows 33 : 13.2% of the population is under 15 years old (national average 13.1%), the ratio of single mother-child households is 1.3% (1.5%), the ratio of dual income households is 25.4% (24.5%), the birth rate of babies weighing under 2, g is 9.5% (9.6%), the number of referrals to a child consultation center (per 1, persons) is 2.2 (2.9), and the ratio of people having completed college and university education is 19.4% (17.3%). Procedures Participants were recruited randomly from the Basic Resident Register in Saitama prefecture using stratified two-stage sampling. First, the prefecture was stratified into three strata depending on the city scale: metropolis (an ordinance-designated city with a population over,), cities (population over,), and towns/ villages. The number of total sampling areas and samples per area were set at 3 and respectively. Thirty sampling areas were assigned to each stratum depending on the population composition of each stratum by proportional distribution. According to the distributed

3 Japanese version of the 93 number of sampling areas, municipalities were randomly extracted as primary sampling units. Each subject was sampled at regular intervals using the Basic Resident Register of the municipalities extracted as primary sampling units. Finally, the questionnaire (J-) was mailed to each subject and was returned by mail. Measures Demographic variables Parents answered questions about sociodemographic variables, including the child s age, gender, birth order, weight and gestational age at birth, parental age, parental education, marital status, and household income. Japanese version of the Infant-Toddler Social and Emotional Assessment (J-) The J- 31 is a Japanese version of the 24, which is an assessment tool for identifying the socialemotional and behavioral problems and competencies in children aged 12 months to 35 months and 3 days. The J- consists of 17 items and is completed by caregivers. The J- items are categorized into four domains; the Externalizing problem domain, Internalizing problem domain, Dysregulation problem domain, and Competence domain. The Externalizing problem domain includes three subscales (Activity/ Impulsivity, Aggression/Defiance, and Peer Aggression), the Internalizing problem domain includes four subscales (Depression/Withdrawal, General Anxiety, Separation Distress, and Inhibition to Novelty), the Dysregulation problem domain includes four subscales (Negative Emotionality, Sleep, Eating, and Sensory Sensitivity), and the Competence domain includes six subscales (Compliance, Attention, Mastery Motivation, Imitation/ Play, Empathy, and Prosocial Peer Relations). In addition, the J- has three clusters of items (Maladaptive, Social Relatedness, and Atypical Item Clusters) that represent behaviors that are rare (less than 5% of the general population). However they may be present in specific psychopathological conditions, such as autism spectrum disorders or psychological trauma. The response format for each item comprises three choices: (not true/rarely), 1 (somewhat true/sometimes), and 2 (very true/often). To calculate a subscale mean raw score, the values for each answered item are summed and divided by the total number of questions. In addition, to obtain the domain mean raw score, the subscale mean raw scores within a given domain are summed and then divided by the number of scored subscales in that domain. Therefore, the possible score range for each domain and subscale is to 2. Higher scores for the problem domains/subscales and lower scores for the competence domain/subscales indicate less favorable behavior. For the four domains, mean raw scores are converted to a T score, which has a mean of and a SD of 1. A T score is calculated using the following formula: (raw score - mean raw score)/sd 1 +. In the original 24, for the problem domains, a T score of 65 and higher is considered of concern for problems. For the competence domain, a T score at or below 35 is considered of concern and reflects a deficit or delay. The subscale and item cluster scores are considered of concern if the raw score is obtained by less than approximately 1% or fewer children of the same gender and age in a normative sample. The J- takes about 25 minutes to complete. Statistical analyses The descriptive statistics of the demographic variables and mean scores and SD of the J- were calculated. The Cronbach s alphas were computed to explore the internal consistency. To examine differences between gender and the four age groups (12-17, 18-23, 24-29, and 3-35 months), the Mann-Whitney U test and Kruskal-Wallis test were used. If any significant difference between age groups was identified, the Mann- Whitney U test with post hoc Bonferroni s correction was performed. The comparison between the J- score and the original score 24 was calculated using a t-test. When the scoring distribution of the J- domain was compared with that of the original 24, T scores (mean raw score in terms of the subscales) were used. In regard to the domain, then the differences in the ratio of children identified as of concern between the and the J- when the same criteria for the cut-off points (T scores that are at or above 65 for the Problem domains, and a T score that is at or below 35 for the Competence domain) was applied to the J- were explored. We estimated cumulative percentages, using linear interpolation with high and low adjacent scores, for the J- domains in which scores corresponding to T scores of 65 (or 35 for the Competence domain) were not observed. The statistical significance of these tests was set at p <.5. SPSS statistics v23 was used for analysis. Ethical consideration The participants were informed in writing about the information regarding the objectives of the study, privacy protection, and the voluntariness of participation. The

4 94 S. Yago et al. J Med Dent Sci study protocol was approved by the ethics committee of Tokyo Medical and Dental University (Receipt no: 1535, date of approval: October 1, 213). Results Demographic variables Of the 1 eligible participants, 659 parents responded to the J- providing a response rate of 43.93%. Seven respondents whose infants had congenital diseases or chromosomal abnormalities were excluded. Participants whose questionnaires had a significant number of unanswered items (n = 23) or who did not meet the infant age criterion (n = 12) were also excluded. Thus, data from 617 respondents were analyzed (valid response rate: 93.63%). The respondents were 582 mothers (94.33%) and 35 fathers (5.67%). The mean age of parents was years (SD = 5.3) and the mean years of education was years (SD = 2.12). The ratio of single-parent households was 2.11%. The most frequent household income of participants ranged from 4,, to 6,, yen (n = 258). See Table 1 for more information about the demographic characteristics of the participants. Score differences between genders and between ages in months The Cronbach s alphas ranged from.76 to.93 for the four domains, and from.45 to.85 for the subscales. Table 2 shows the mean score and SD by gender. For the Externalizing problem domain, boys scored significantly higher compared to girls (p <.1). On the other hand, girls scored higher on the Internalizing problem and Competence domains compared to boys (p <.1). In terms of the subscales, compared to girls, boys were rated higher on Activity/Impulsivity and lower on Inhibition to Novelty and all subscales of the Competence domain. Score differences between the four age groups were identified for the Externalizing problem (p <.1), Internalizing problem (p <.5), and Competence (p <.1) domains (Table 3). The results of the multiple comparisons revealed significant differences between months and the other three age groups for the Externalizing problem domain, and between months and months for the Internalizing problem domain (Figure 1). In addition, the Competence domain score significantly increased across age groups (Figure 1). There was no significant interaction between gender and age for any domains or subscales. Comparison of the J- score with the standard score The mean J- domains/subscales scores were compared with that of the original s normative sample 24 (Table 4). For both boys and girls, the scores of the J- were significantly lower than of the for the Competence domain (p <.1). Regarding the subscales, the scores of the J- were higher for Aggression/Defiance, Separation Distress, Negative Emotionality, and Imitation/Play, and were lower for Peer Table 1. Participant s demographic data (N = 617) Total Boys Girls n % n % n % Total Age months months months months Gestational age 37 weeks < 37 weeks Birth weight 2 g < 2 g Birth order First Second Third or later Residential area Metropolis Cities Towns/Villages Note. The sum of demographic data is not always, as some values for gestational age (n = 1), birth weight (n = 5), and birth order (n = 59) were missing.

5 Japanese version of the 95 Table 2. Mean scores and standard deviations for the Japanese version of the Infant-Toddler Social and Emotional Assessment domains, subscales, and item clusters and results of the comparison of scores between boys and girls (N = 617) Total Boys Girls Domain/Subscale/Item Cluster n Mean SD n Mean SD n Mean SD p Externalizing Domain ** Activity/Impulsivity ** Aggression/Defiance ns Peer Aggression ns Internalizing Domain ** Depression/Withdrawal ns General Anxiety ns Separation Distress ns Inhibition to Novelty ** Dysregulation Domain ns Negative Emotionality ns Sleep ns Eating ns Sensory Sensitivity ns Competence Domain ** Compliance ** Attention ** Mastery Motivation * Imitation/Play ** Empathy ** Prosocial Peer Relations * Maladaptive Item Cluster ns Social Relatedness Item Cluster ** Atypical Item Cluster * Note. Mann-Whitney U test. *p <.5. **p <.1. Table 3. Mean scores and standard deviations for the Japanese version of the Infant-Toddler Social and Emotional Assessment domains, subscales, and item clusters according to age group (N=617) months months months 3 35 months Domain/Subscale/Item Cluster n Mean SD n Mean SD n Mean SD n Mean SD p Externalizing Domain ** Activity/Impulsivity ns Aggression/Defiance ** Peer Aggression * Internalizing Domain * Depression/Withdrawal * General Anxiety ** Separation Distress ** Inhibition to Novelty ** Dysregulation Domain ns Negative Emotionality ns Sleep ** Eating ** Sensory Sensitivity ns Competence Domain ** Compliance ** Attention ** Mastery Motivation ** Imitation/Play ** Empathy ** Prosocial Peer Relations ** Maladaptive Item Cluster * Social Relatedness Item Cluster ** Atypical Item Cluster ** Note. Kruskal Wallis Test. *p <.5. **p <.1.

6 96 S. Yago et al. J Med Dent Sci 1.6 ** a * raw score * ** * * Externalizing Internalizing Competence Figure Figure 1. Score 1. Score differences differences in in Externalizing, the Externalizing, Internalizing, Internalizing, and Competence and Competence domains between the four age groups (in months) Note. Mann-Whitney U test post hoc Bonferroni s correction. *p<.5. **p<.1. a Significant differences (p<.1) were found between the age groups in the Competence domain, except between months and 3-35 months. Aggression, Sensory Sensitivity, Compliance, Attention, Mastery Motivation, and Empathy compared to the. These results were true for both genders. When the T scores of the four domains were interpreted according to the criteria in the original, the difference in the ratio of children identified as of concern between the two instruments ranged from -2.4% to 4.64% for the Externalizing problem domain, from -4.48% to 2.29% for the Internalizing problem domain, from -5.3% to 2.48% for the Dysregulation problem domain, and from -3.97% to 3.46% for the Competence domain (Table 5). This indicates that 5.3% fewer Table 4. Comparison of scores between the original and the Japanese version of the Infant-Toddler Social and Emotional Assessment according to gender Boys Girls J- J- Domain/Subscale n Mean SD n Mean SD p n Mean SD n Mean SD p Externalizing Domain ns ns Activity/Impulsivity ns ** Aggression/Defiance ** * Peer Aggression ** ** Internalizing Domain ns ** Depression/Withdrawal * ns General Anxiety ns ns Separation Distress ** ** Inhibition to Novelty * ns Dysregulation Domain ns ns Negative Emotionality * * Sleep ns ns Eating ns ns Sensory Sensitivity ** ** Competence Domain ** ** Compliance ** ** Attention ** ** Mastery Motivation ** ** Imitation/Play ** ** Empathy ** ** Prosocial Peer Relations ns ns Note. T-test. : Infant-Toddler Social and Emotional Assessment; J-: Japanese version of the Infant-Toddler Social and Emotional Assessment. *p <.5. **p <.1. Adapted from Infant-Toddler Social and Emotional Assessment examiner s manual, by Carter AS, Briggs- Gowan MJ, 26, San Antonio: Harcourt Assessment, Inc. Copyright 26 by Yale University and the University of Massachusetts.

7 Japanese version of the 97 Table 5. Proportions of children identified as of concern in the original and the Japanese versions of the Infant-Toddler Social and Emotional Assessment Boys Girls months months months 3 35 months months months months 3 35 months Domain I J-I I J-I I J-I I J-I I J-I I J-I I J-I I J-I Externalizing Internalizing Dysregulation Competence Note. I = Infant-Toddler Social and Emotional Assessment, J-I = Japanese version of the Infant-Toddler Social and Emotional Assessment. Adapted from Infant-Toddler Social and Emotional Assessment examiner s manual, by Carter AS, Briggs-Gowan MJ, 26, San Antonio: Harcourt Assessment, Inc. Copyright 26 by Yale University and the University of Massachusetts. children or 4.64% more children are possibly identified as requiring additional assessment or intervention in the J- compared to the original. Furthermore, there were considerable differences in the scoring distribution on various subscales. For example, it was found that distributional differences in the Compliance, one of the subscale of the Competence, regardless of child s gender and age (Figure 2). Discussion Gender and age differences in the J- This study provides the norms of scores for the J- that can be used for interpreting results in a clinical setting. In addition, it shows that there were significant differences in social-emotional/behavioral problems and competencies between gender and Boys Girls months old J- 1 2 J months old J- 1 2 J months old J- 1 2 J months old J- 1 2 J- 1 2 Figure 2. Comparison of the scoring distribution of the Japanese version of the Infant-Toddler Social and Emotional Assessment with the original Infant-Toddler Social and Emotional Assessment for the Compliance subscale by gender and age groups Note. The vertical and horizontal axes represent cumulative percent and raw score respectively. = Infant-Toddler Social and Emotional Assessment; J- = Japanese version of the Infant-Toddler Social and Emotional Assessment.Adapted from Infant-Toddler Social and Emotional Assessment examiner s manual, by Carter AS, Briggs-Gowan MJ, 26, San Antonio: Harcourt Assessment, Inc. Copyright 26 by Yale University and the University of Massachusetts.

8 98 S. Yago et al. J Med Dent Sci age. The J- rating demonstrated that boys had more externalizing problems compared to girls, such as overactivity and impulsivity, while girls were more likely to have internalizing problems, such as inhibition to novelty. These results are consistent with evidence derived from a sample of Japanese children using the Child Behavior Checklist and the Strength and Difficulties Questionnaire 21, 22. Moreover, the prevalence of Attention Deficit Hyperactivity Disorder, which involves significant overactivity and impulsivity, has been reported to occur two to three times more in boys than in girls 34. In the original, the score of boys for Activity/Impulsivity was higher than of girls 24. For the Competence domain and its subscales, girls scored consistently higher than boys, and the same results were found for the 24. The gender differences in social competence have been reported in prior studies into the development of empathetic and prosocial behavior in infants under 2-years-old 35, 36. The scores of the J- varied between the four 6-month age groups. In particular, the score of the Competence domain significantly increased with increasing age. Typically, infants and toddlers develop their social competencies through interaction with parents, grandparents, siblings, or childcare providers in a gradual manner 37. The development of empathy, for instance, gradually proceeds with the growth of interpersonal recognition 37, while the frequency and variety of prosocial behavior, such as sharing, helping, and comforting, increases from 1- to 2-years-old 38. The significant score differences on the J- among gender and four age bands in this study implied that we should develop national norms for the J- by genders and four age bands that is months, months, months, and 3-35 months based on the data from the current study for the valid interpretation of the meaning of a given child s score on the J- in the same way as the original 24. Score differences between the J- and the original For some domains and subscales, the mean scores were significantly different between the J- and the original. The possible reasons for these differences include cultural differences between Japan and the US and differences in sampling methods. In this study, the overall J- Competence domain score, excluding scores for Imitation/Play and Prosocial Peer Relations subscales, was significantly lower relative to that of the original. This difference indicated that American infants and toddlers exhibited a higher number of social competencies relative to that of Japanese children. Bronfenbrenner 39 conceptualized the ecological structure relating to a child s development and described a model composed of four systems around the child that include the microsystem, mesosystem, exosystem, and macrosystem. The macrosystem, the outermost system, constitutes the child s society and culture with particular reference to the belief system, lifestyle, values, and pattern of social interaction. As a child s social behavior is carried out in their social and cultural context, this factor cannot be ignored. Kashiwagi 4 explored what Japanese and American mothers regarded as the most important aspects of preschool education, and revealed that Japanese mothers placed more importance on the education of school related skills, such as reading and calculating, whereas American mothers gave more weight to independence and social skills. The same study 4 suggested that Japanese mothers expected emotional maturity in their children earlier, while American mothers expected the development of verbal assertiveness (expressiveness) and social skill earlier. These differences in parental expectation for education and development between the two countries might influence the development of children through parental behaviors. Moreover, the employment rate of American mothers who have children under 3-years-old is approximately double that of Japanese mothers 41. As American children have the opportunity for more contact with other people outside of family members from early childhood, it might affect the higher development of social-emotional competencies. In addition, Japanese children experience less separation from parents than American children, which might result in the higher score of the Separation Distress subscale for both genders of Japanese children. The scores of Aggression/Defiance on the J- for both boys and girls were significantly higher relative to those for the original. Interestingly, in contrast, J- Peer Aggression scores were significantly lower relative to those for the original. This result indicated that Japanese toddlers and infants tended to be more aggressive toward their parents and less aggressive toward their peers relative to American children. Aggression assessed by the J- includes both reactive aggression and proactive aggression. Given that reactive aggression is strongly affected by inherent factors 42 and proactive aggression is acquired through the social learning 43, the scores were likely to be influenced by social and cultural factors. The differences in aggression between the two countries might be explained by the characteristics of the child rearing

9 Japanese version of the 99 strategy in Japan and the US. The American parent-child relationship is more authoritarian, and parents strictly control undesirable behavior 44. Meanwhile, Japanese parents consider officially that the child is essentially good and they just do not know that their behaviors are not desirable in the situation, and they make an effort to explain the outcome or refer to a person s feelings resulting from the problem behavior so that the child is able to understand their mistake 44. In addition, if the child does not understand the parents in spite of their efforts, the parents try to avoid confrontation with the child, and instead aim to be moderate or to compromise 44. Within the Japanese specific parent-child relationship, especially within the mother-child relationship, the child s aggression and defiance toward parents is allowed to some extent or is not controlled so strictly. Moreover, people in Japan are required to adjust their behavior properly between in-family (uchi) and out-family (soto) situations 44. As Japanese children may acquire the differentiation between in-family and out-family early, they might suppress their aggression against participants outside of the family, such as peers. The second possible factor involves the difference in sampling methods for normative samples between the J- and the original. In the original, 6 participants were sampled at different sites across 42 states in the US using stratified ethnicity, parent education level, and region, matching the 22 US census 24. In this study, we did not perform a nationwide survey. Therefore, the participants did not always represent the Japanese population. However, we did adopt a strict random sampling method. In addition, the mean years of parental education in this study was comparable to that of the Japanese and American 25 to 34-year-old women s education (13.2 and 13.4 years, respectively) 45. Although the possibility that using different sampling methods caused the score differences between the two instruments is undeniable, its influence may not be conclusive. We also examined the assignment of the cut-off points in the J-. When the T scores of the four domains were interpreted according to the criteria in the original, the differences in the proportion of children who were identified as of concern between the J- and the original ranged from -5.3% to 4.64% (Table 5). Similarly, for the subscales, the score distributions apparently differ between the J- and the original (Figure 2). In light of the differences in the scoring distribution and mean score within a normative sample, applying the same criteria as the original to both domains and subscales in the J- might be invalid. In future studies, it is essential to develop the cut-off points specific to the J- by comparing the scores of clinical groups, such as autism spectrum disorders, with those of a control group. Strengths and limitations of the J- in Japanese primary care settings In Japan, it is increasingly required of professionals working with infants and toddlers in primary care settings to identify children with social-emotional/behavioral problems or delays in competence as early as possible and to provide support in an appropriate fashion. The J- is a reliable and valid instrument 31 and can be applied to one-year-old children. It allows the assessment of children s problems (weaknesses) as well as their competencies (strengths) and enables the provision of an intervention that adopts a strength-based approach. It is easy to use in the primary care setting without imposing a large burden on the parents and children. Moreover, by using the instrument longitudinally, we are able to monitor change in the child and to evaluate the effectiveness of the intervention. The findings in this study provide useful data about characteristics of the J- and development of the norms that it allows to locate relative position of the given scores and to interpret them within the distribution of the Japanese normative sample. However there are still several limitations of its application in Japanese practice. First, the standard sample of this study were not obtained from the whole country but from a certain prefecture in Japan. Second, the cut-off points that are appropriate for the J- have not yet been obtained. Therefore further investigation will be needed to set criteria of the cut-off points for the J- by comparing the scores of clinical group with those of control group. And as a limitation of the J- itself, we can point out that it requires relatively long time (about 25 minutes) to complete it. To enhance the capacity of the instrument in a screening setting, the development of a brief version of the J- is needed in the same way as the original 46. Furthermore we should keep in mind that the J- is not a diagnostic tool, nor is it designed to be used in isolation to determine the need for intervention. The J- scores that are provided by parents will be influenced by several factors, such as their own mental health, their expectation of child development, and their values and beliefs 47. Thus, it is essential to supplement the results of the J- with comprehensive information, such as direct observation of a child s behavior and parent-child interaction, and a semi-structured interview about the onset, duration,

10 S. Yago et al. J Med Dent Sci frequency, intensity, and contextual factors of the problem behaviors. In addition, gathering information from other caregivers (e.g., partners or childcare providers) may be useful. Furthermore, it is important to pay attention to psychosocial stressors relating to the child s mental health, such as the birth of a sibling, death of a significant other, marital conflict, and divorce 25. The J- may allow professionals, beginning with nurses, to obtain a comprehensive profile of a child s development, to clarify the need and method of support, and to launch an intervention at a very early stage of development. This would prevent secondary impairments occurring as a result of the problem behaviors, assist with the child s healthy development, foster the parentchild relationship, and promote secure attachment. The J- is a useful assessment tool for the Japanese primary care setting. Conclusion In this study, the J-, an assessment tool for identifying social-emotional/behavioral problems and delays in competence in 1- to 3-year-old infants and toddlers, was applied to a Japanese community sample. The norms of the scores on the J-, and the score differences between genders and ages (in months) and between the J- and the original, were revealed. It is suggested that any obtained scores on the J- should be interpreted in comparison with the norms developed separately by gender and the four age groups (12-17 months, months, months, and 3-35 months) in the current study. Furthermore, it is indicated that using the same criteria for the cut-off points in the J- as in the original is invalid and specific cut-off points for the J- are required. Acknowledgments The authors sincerely thank the participants and the graduate students of the section of Child and Family Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University. References 1. Ministry of Education, Culture, Sports, Science and Technology. Survey results for students in need of special education support of possible developmental disabilities enrolled in regular classes (in Japanese) 2. American Academy of Pediatrics, Committee on Children with Disabilities. Developmental surveillance and screening of infants and young children. Pediatrics. 21; 18: American Academy of Pediatrics. Identifying infants and young children with developmental disorders in the medical home: an algorithm, for developmental surveillance and screening. Pediatrics. 26; 118(1): Ministry of Health, Labor and Welfare. Developmental Disabilities Assistance Act. 25. (in Japanese) 5. Anderson GM, Cohen DJ. Genesis of neocortex. In: Lewis M, editor. Child and Adolescent Psychiatry: Comprehensive Textbook. 3 rd ed. Philadelphia: Lippincott Williams & Wilins; 22: Newth SJ, Corbett J. Behavior and emotional problems in three-year-old children of Asian percentage. J Child Psychol Psychiatry. 1993; 34(3): Lavigne JV, Gibbons RD, Christoffel KK, et al. Prevalence rates and correlates of psychiatric disorders among preschool children. J Am Acad Child Adolesc Psychiatry. 1996; 35(2): Briggs-Gowan MJ, Carter AS, Moye Skuban E, et al. Prevalence of social emotional and behavioral problems in a community sample of 1- and 2-year-old children. J Am Acad Child Adolesc Psychiatry. 21; 4(7): Egger HL, Angold A. Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. J Child Psychol Psychiatry. 26; 47(3/4): Earls F. Prevalence of behavior problems in 3-year-old children. Ach Gen Psychiatry. 198; 37: Shaw DS, Keenan K, Vondra JI. Developmental precursors of externalizing behavior: Ages 1 to 3. Dev Psychol. 1994; 3(3): Keenan K, Shaw DS, Delliquadri E, et al. Evidence for the continuity of early problem behaviors: application of a developmental model. J Abnorm Child Psychol. 1998; 26(6): Briggs-Gowan MJ, Carter AS, Bosson-Heenan J, et al. Are infant-toddler social-emotional and behavioral problems transient? J Am Acad child Adolesc Psychiatry. 26; 45(7): Briggs-Gowan MJ, Carter AS. Social-emotional screening status in early childhood predicts elementary school outcomes. Pediatrics. 28; 121: Sasamori H, Gokami T, Kuboyama S, et al. Current situations and problems for early detection and early support for children with developmental disability. Bulletin of the National Institute of Special Needs Education. 21; 37: (in Japanese) 16. Ministry of Health, Labor and Welfare. Manual of awareness and support for children with mild developmental disorders. 26. (in Japanese) 17. Inaba F, Kimura R, Tsuda A. Awareness of public health nurse and related factors regarding screening for infants with developmental disorders at infant medical examination. Journal of Tsuruma Health Science Society Kanazawa University. 214; 38(1): Asperger Society Japan. Guideline for support and assessment of persons with developmental disabilities.

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