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RESEARCH ARTICLE
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Citation: Najmussaqib A, Mushtaq A (2023)
Estimation and linkage between behavioral
problems and social emotional competence among
Pakistani young school children. PLoS ONE 18(5):
e0278719. https://doi.org/10.1371/journal.
pone.0278719
Editor: Supat Chupradit, Chiang Mai University,
THAILAND
Received: September 9, 2022
Accepted: November 21, 2022
Published: May 25, 2023
Copyright: © 2023 Najmussaqib, Mushtaq. This is
an open access article distributed under the terms
of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: The minimal data is
uploaded at the following Public repository: https://
osf.io/8h7pr/?view_only=
548e2c59c2bf4aed8688d6b627fb5db6.
Funding: The author(s) received no specific
funding for this work.
Competing interests: The authors have declared
that no competing interests exist.
PLOS ONE | https://doi.org/10.1371/journal.pone.0278719 May 25, 2023
Estimation and linkage between behavioral
problems and social emotional competence
among Pakistani young school children
Arooj Najmussaqib ID*, Asia Mushtaq ID
Department of Applied Psychology, National University of Modern Languages, Islamabad, Pakistan
* aroojnajm@gmail.com
Abstract
Behavioral problems are commonly occurring concerns in school children and if left unidenti-
fied can result in worse outcomes in any society. The research aims to explore the preva-
lence of behavioral problems and its association with social emotional competence in young
school children from a community sample of Islamabad, Pakistan. The cross-sectional
study was conducted from April to June 2021 in four public primary schools in Islamabad,
Pakistan. Two stage cluster sampling was used to select study sites. The sample comprised
426 school children (males = 182, females = 195) aged 4–8 years (Mean age = 6.5, SD =
1.09), from three different grades kindergarten, 1, and 2, respectively. The Child Behavior
Checklist (CBCL) and Social Emotional Development Assessment (SEDA) were used to
screen behavioral problems and social emotional competences of children. Data were ana-
lyzed using Stata 17. Prevalence for overall behavioral problems accounted for 65.4% (4–6
years) and 36.2% (6–8 years) in the abnormal (borderline and clinical) ranges of total prob-
lems. Social emotional competence scores were found significantly negatively associated
with behavioral problems of children. The high prevalence necessitates the provision of
mental health care to school-aged children. The findings should be taken as a call to Paki-
stan’s policymakers, clinicians, and researchers to develop proper screening and manage-
ment protocols for early intervention.
Introduction
Mental illnesses in children have been identified as a significant public health concern and one
of the leading causes of disability and economic costs to society [1]. Suffering, functional
impairment, stigma and discrimination, and an increased risk of premature death are all asso-
ciated with mental health problems [2,3]. According to global epidemiological data, 13 to 23%
of children and adolescents have a mental disorder [4,5]. Early age mental health problems
(MHP) endanger a child’s life. Therefore, during the last few decades, researchers’ focus has
shifted from adults to preschool and young children’s mental health prevalence [6].
Numerous studies on young children indicate that mental health problems show remark-
able stability and strongly predict mental disorders in adulthood [7]. In addition, Basten et al.
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PLOS ONE Behavioral problems and Social-emotional competence

(2016) [8] showed that a heterotypic continuity (i.e., one disorder predicting another at a later
time point) of symptom patterns is common as children age. In a recent national survey of
United States [9], mental health disorders were reported in 41% of children aged six to eleven.
According to the findings, preschool children had a comparatively high rate of borderline
behavior problems (46.5%). One in eighteen (5.5%) preschool children were identified with a
mental disorder, with higher rates in males (6.8%) than in females (4.2%). Researchers have
categorized behavioral problems as internalizing and externalizing problems. Internalizing
problems are defined as anxious and depressive symptoms, social withdrawal, and somatic
complaints. Externalizing problems on the other hand are categorized as aggressive, opposi-
tional, and delinquent behavior. Children having internalizing or externalizing symptoms may
have challenges as long-term consequences within social, academics and later professional
environment [10]. Alarmingly, internalizing problems have steadily increased in children, up
from 4.3% in 1999 and 3.9% in 2004 to 5.8% by 2017 [11]. Furthermore, children with exter-
nalizing problems significantly predict Internet Gaming disorder, whereas internalizing prob-
lems predict Internet Addiction [12,13].
In Pakistan, mental health services are the most neglected, with 10–16 percent of the popu-
lation, or more than 14 million people, suffering from mild to moderate mental diseases
[14,15]. Data from limited studies conducted in Pakistan using different assessment measures
revealed that approximately 34.4% of school children suffer from mental health problems
[16,17]. A recent telephonic survey [18] from parents using strengths and difficulty question-
naire (SDQ) showed a 15.9% prevalence of overall behavior problems in children aged 6–16
years. Furthermore, estimates for conduct problems were about 26.6%, emotional problems
22.5%, peer problems 13%, hyperactivity 10.6%, and social problems 3%. Another research
with preschool children [19] observed a significant percentage of borderline behavior prob-
lems (46.5%). Author reported significant gender differences, with males scoring higher on
externalizing problems than females. However, there is no empirical evidence of using teach-
ers’ reports in a cross-sectional study design to investigate emotional and behavioral difficul-
ties in young school children aged 4–8 years.
In addition to the concerns about behavioral problems, these issues may manifest as a result
of children’s own individual difficulties with social emotional competence [20]. Social emo-
tional skills are strongly associated with children’s trajectory of development of internalizing
and externalizing problems during early childhood [21]. Considerable literature demonstrates
that children’s social emotional competence serves as potential protective factors for challeng-
ing life events and are not limited to immediate wellbeing [22]. Recent studies in several Asian
countries recommended and highlighted the importance of school based mental health care to
develop social emotional skills in children [23]. Teaching social emotional skills such as emo-
tions understanding and regulation, prosocial behaviors, and social skills at early age have
found to be improving learning behavior, wellbeing, inattention, aggression and depressive/
withdrawn behaviors [24,25]. Experts from Pakistan also recommended need of social emo-
tional skills development of children as a remedy to reduce behavioral problems [18,19]. How-
ever, not much research work is done in the respective area of social emotional competence.
Due to the scarcity of local research with respect to young school children, our primary goal in
this study was to assess the estimates of internalizing and externalizing problems in young
school children. Another aim of this study was to assess the associations between social emo-
tional competence, internalizing and externalizing problems (IEPs) in young Pakistani school
children aged 4–8 years.

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PLOS ONE Behavioral problems and Social-emotional competence

Method
The present study was part of a PhD research project. Inclusion criteria was based on curricu-
lum age group(4–8 years) comprised of males and females.

Study design
The present study is based on cross sectional study design. It was carried out in April–June
2021 in four public sector schools of Islamabad, Pakistan after obtaining ethical approval from
board of studies of National Language of Modern Languages, Islamabad and official permis-
sion from Federal Directorate of Education, Islamabad.

Participants
The target population was school children aged 4–8 years as per the requirement of the inter-
vention curriculum. Therefore, inclusion criteria were age range of 4-8years, both males and
females enrolled in public schools from three grade levels, i.e., kindergarten, grade one, and
grade two. A sample of 426 eligible students (48.48% males) was drawn from 15 classes and
four public schools.

Sampling and procedure

Two staged cluster sampling technique was used to induct schools and study participants. As a
first step, permissions were sought from the Federal Directorate of Education (FDE), Islama-
bad. The permission application took 6.5 months due to covid-19 as initial lockdowns were
occurring all over Pakistan, including Islamabad. Since the present study was part of interven-
tion project, only primary schools’ data was requested from Federal Department of Education.
The permission was granted in November 2020 to conduct the study, and FDE nominated
four public primary schools in Islamabad. As a second step, meetings were arranged with
school principals to discuss the administrative requirements. They nominated fifteen teachers
from respective classes for the training and facilitation during the research project. Written
consent was taken from the teachers, and due to covid restrictions of social and public meet-
ings, parents were approached through letters from the schools. Trained research assistants
administered a child report instrument in small groups. Another set of assessment protocol
was completed by teachers for each child using pen and paper method.
A statistical power analysis was performed using G-power software for sample size estima-
tion, based on data from the meta-analysis [26], comparing school-based studies for depres-
sion and anxiety programs. With an estimated small effect size [27] of 0.25, an alpha = .05, and
power = 0.80, the projected sample size was 98. Hence, the initial total sample size of N = 464
was deemed adequate for the main objective of this study and should also allow for expected
attrition. The current study’s sample consisted of 426 school children (males = 206,
females = 220) recruited from four public sector schools in Islamabad, Pakistan. Children were
from 4-8years of age (Mean age = 6.3 years, SD = 0.84) belonging to three classes Kindergarten,
grade one, and grade two, respectively. 24 teachers (two from each class as per nominated by
school administration) completed the outcome measures.

Measures
Behavioral problems were measured using teacher reported Urdu versions of Child Behavior
Checklist (CBCL) [28]. Whereas, social emotional competence was assessed using translated
version of child reported measure of Social Emotional Development Assessment (SEDA) [29].

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PLOS ONE Behavioral problems and Social-emotional competence

1. Demographic form. A form was developed to obtain data about the sample’s various
demographic variables including gender, age, family income and family system.
2. Child behavior checklist (11/2-5)-CTRF. Children (aged 4–5 years) behavior problems
were measured through the Teacher Reported Urdu Version of Child Behavior Checklist
(CBCL-CTRF) [29], 99 items. It has six empirically based syndrome scales: Emotionally
Reactive, Anxious/Depressed, Somatic Complaints, Withdrawn, Attention Problems, and
Aggressive Behavior. These syndrome scales broadly form two subcategories of behavioral
problems, namely “internalizing” and “externalizing.” Scoring is done on 3-point scale,
where 0 = not true, 1 = sometimes true, and 2 = often true or very true. Raw scores were
converted to T scores and percentiles as per the scoring criteria. The Cronbach’s alpha coef-
ficient of the original measure was .88 for the total problem scale and .89 and .77 for exter-
nalizing and internalizing subscales, respectively.
3. Child behavior checklist (16–18)-TRF. This teacher reported Urdu version of CBCL- TRF
was used for children above five years of age. It is also a Likert-type scale comprised of 112
items scoring on 3-point scale, where 0 = not true, 1 = sometimes true, and 2 = often true
or very true. There are eight empirical-based syndrome scales named Anxious/Depressed,
Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems, Atten-
tion Problems, Rule Breaking Behavior, and Aggressive Behavior [28]. This scale also has
two broader categories of internalizing and externalizing problems. Raw scores were con-
verted to T scores and percentiles as per the scoring criteria. The original measure’s Cron-
bach’s alpha coefficient was.97 for the total problem scale and.95 and.90 for the
externalizing and internalizing subscales, respectively. Both scales’ validity is extensively
established around the world.
4. Social Emotional Development Assessment (SEDA). Social Emotional Development
Assessment (SEDA) [29] scale consisting of 12 self-report items rated on a 0–2 (i.e., “not
true or rarely true” as indicated by a thumbs down clip art, “sometimes true” as indicated
by a sideways thumbs clip art, “usually or always true” as indicated by a thumbs up clip art)
that are used to assess social emotional skills in children from kindergarten to 2nd grade
across five domains: self-regulation, social skills, school belongingness, social responsibility,
and optimism. Where, school belongingness and optimism have 3 items each and rest of
the domains have 2 items (e.g., I wait my turn in line, I invite kids to play with me, I like
myself). The scale evidenced adequate internal consistency (α = 0.83).

Analytical plan
All analyses were conducted using Stata 17.0 [30]. Descriptive statistics were computed includ-
ing frequencies, percentages for all problems for different categories (e.g., borderline and clini-
cal). These results provided details for the estimates of the internalizing and externalizing
problems in children. We than examined bivariate correlations to assess the associations
between study variables such as behavioral problems (IEPs) and social emotional competence
(SEDA).
The initial analysis for each dependent variable examined the main effects for the four inde-
pendent variables of age groups (1 = 4+, 2 = 5+, 3 = 6+ and 4 = 7+ years) using univariate anal-
ysis of variance (ANOVA). Partial eta squared was selected for measuring the effect size. Then,
multiple linear regression analyses were done to assess the associations between the SEC and
IEPs.

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PLOS ONE Behavioral problems and Social-emotional competence

Ethical considerations
Initially, permission was sought from the Federal directorate of Education, Islamabad, to con-
duct the study. Nominations for schools were received, and teachers were later asked to pro-
vide the consent form and demographic information form to the parents. They were informed
about the goal of the research and ensured that the information would only be utilized for
research reasons. Class teachers who had been supervising the children for at least six months
were asked to rate the children’s behaviors in class and during school hours using the respec-
tive scales followed by consent. All the information is coded and all the identifiable informa-
tion has been removed from the dataset to protect the participants’ individual privacy.

Results
The present study aimed at exploring prevalence and estimation of behavioral problems and its
association with social emotional competence in young children of Pakistan. For this purpose,
426 [males:206 (48.4%), females:220 (51.6%)] participated from three different grades, i.e., Kin-
dergarten (53.3%), 1st (30.8%) and 2nd (16%) respectively. The average age of the sample group
is 6.3 (SD = 0.84) years. The mean individual household income was 25,365 PKR (SD = 11,527)
(approximately USD-100) having nuclear family structure (62.4%). Table 1 presents the psycho-
metric properties of the measures used in the study, whereas Table 2 presents the estimates of
internalizing, externalizing and total problems of children of both age groups and gender.

Psychometrics of the scales

The psychometrics of the scales used in the present study are presented in Table 1. The mean
score on a total of the CBCL- CTRF was 54.55 (SD = 32.2). The mean score on internalizing
and externalizing scales was 18.27 (SD = 10.74) and 18.1 (SD = 11.29) respectively. Whereas
the mean score on the total of the CBCL- TRF was 37.26 (SD = 38.08). The average score on
internalizing and externalizing scales was 8.94 (SD = 9.93) and 9.81 (SD = 11.83) respectively.
Table 1 indicates alpha co-efficient and skewness of Urdu version of CBCL-CTRF,
CBCL-TRF and SEDA. Internal consistency was high for both total scales and all subscales,
implying that the scales are relevant and acceptable for Pakistani school children.

Prevalence of behavioral problems

The present study sample showed that 65.4% children (4–6 years) and 36.2% children (6–8
years) have total behavioral problems as assessed by CBCL. For internalizing problems, esti-
mates were 68% for younger children (4–6 years) and 39.9% for older children (6–8 years). For
externalizing problems, estimates were 50% for younger children (4–6 years) and 37.6% for
older children (6–8 years) Table 2 shows the categorization of both age groups and gender.
Further categorization of children was done based on the teacher’s rating on CBCL scales.
Among children aged 4–6 years, 6.4% were categorized as having borderline behavioral prob-
lems, while 59% were rated in the clinical range in total problems. On the internalizing sub-
scale, 9% of children were borderline, 59% were placed in the clinical range. On externalizing
subscale, 20.5% of children were categorized as borderline, and 29.5% were reported in the
clinical range.
Additionally, males showed higher abnormal (borderline and clinical) ratings in the overall
internalizing domain (32%) with higher anxious/depressed domain, whereas; females were
found higher in the somatic and withdrawn behaviors. Both showed equal in emotional reac-
tivity. On the other hand, females were reported as having higher abnormal (borderline and
clinical) in both overall externalizing (33.3%) and total problem scores (39.7%).

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PLOS ONE Behavioral problems and Social-emotional competence

Table 1. Psychometrics of CBCL-CTRF (n = 78), CBCL-TRF (n = 348) and SEDA (N = 426).

Range
Variables No of items M SD α Potential Actual Skew Kurt
CBCL(11/2-5)- CTRF
Internalizing problems* 32 18.27 10.743 0.834 0–64 0–48 -0.009 -0.561
Emotionally Reactive 7 4.01 2.789 0.732 0–14 0–11 0.300 -0.646
Anxious/Depressed 8 4.90 3.234 0.737 0–16 0–14 0.348 -0.359
Somatic complaints 7 3.73 2.719 0.720 0–14 0–10 0.288 -0.972
Withdrawn 10 5.63 3.561 0.720 0–20 0–15 0.222 -0.385
Externalizing problems* 34 18.10 11.295 0.883 0–68 0–52 0.369 -0.175
Attention problems 9 5.32 3.547 0.736 0–18 0–15 0.442 -0.085
Aggressive behavior 25 12.78 8.360 0.734 0–50 0–37 0.287 -0.420
Other problems 34 18.18 11.582 0.741 0–68 0–48 0.238 -0.692
Total* 100 54.55 32.200 0.879 0–200 0–148 0.128 -0.446
CBCL(6–18)- TRF
Internalizing problems* 27 8.94 8.935 0.827 0–54 0–38 1.077 0.350
Anxious/Depressed 16 5.48 5.619 0.748 0–32 0–24 1.099 0.438
Withdrawn/depressed 8 2.63 2.820 0.746 0–16 0–15 1.348 1.937
Somatic complaints 3 0.84 1.358 0.822 0–6 0–6 1.912 3.514
Externalizing problems* 32 9.81 11.830 0.911 0–64 0–52 1.380 0.906
Rule-breaking 12 3.40 4.391 0.759 0–24 0–19 1.438 1.178
Aggressive behavior 20 6.41 7.793 0.756 0–40 0–33 1.390 0.947
Other problems 6 2.18 2.436 0.747 0–12 0–10 1.270 0.878
Social problems 11 3.85 4.329 0.759 0–22 0–19 1.213 0.705
Thought problems 10 2.73 4.025 0.769 0–20 0–16 1.469 1.143
Attention problems 26 9.74 9.129 0.908 0–52 0–41 1.095 0.639
Total* 112 37.26 38.084 0.796 0–224 0–163 1.249 0.657
SEDA
Self-Regulation 2 3.66 0.691 0.850 0–4 0–4 -2.324 5.982
Social skills 2 3.68 0.705 0.842 0–4 0–4 -2.523 6.879
School belongingness 3 5.33 0.908 0.743 0–6 0–6 -1.295 1.347
Social responsibility 2 3.65 0.820 0.850 0–4 0–4 -2.587 6.599
Optimism 3 5.75 0.603 0.678 0–6 0–6 -2.537 6.532
Total 12 22.07 2.451 0.713 0–24 0–9 -1.803 4.199

M = mean; SD = standard deviation; α = reliability coefficient; Skew = skewness; Kurt = Kurtosis.

* Scores are based on T-scores.

https://doi.org/10.1371/journal.pone.0278719.t001

Among children aged 6–8 years, 12.1% were categorized as having borderline behavioral
problems, while 24.1% were rated in the clinical range in total problems. On the internalizing
subscale, 8.6% of children were borderline, and 31.3% were ranked in the clinical range (see
Table 2). On externalizing subscale, 9.2% of children were categorized as borderline, and
28.4% were reported in the clinical range. According to teacher reports, Figs 1 and 2 provides
an illustrative view of percentages for clinical ranges of males and females.
In the higher age group (6–8 years), males again showed higher abnormal (borderline and
clinical) ratings in the overall internalizing domain (21%) with higher anxious/depressed,
somatic and withdrawn behaviors. Furthermore, males showed slightly higher abnormal (bor-
derline and clinical) ratings in the overall internalizing domain (21%) with more elevated anx-
ious/depressed, withdrawn and somatic complaints subscales.

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Table 2. Estimates of internalizing and externalizing problems in young school children (N = 426).
Variables Normal Borderline Clinical
CBCL(1 1/2-5)- CTRF Males Females Total Males Females (%) Total n (%) Males Females Total
n (%) n (%) n (%) n (%) n (%) n (%) n (%)
Internalizing Problems 12(15.4) 13(16.7) 25(32.1) 4(5.1) 3(3.8) 7(9) 21(26.9) 25(32.1) 46(59)
Emotionally Reactive 22(28.2) 22(28.2) 44(56.4) 7(9) 11(14.1) 18(23.1) 8(10.3) 8(10.3) 16(20.5)
Anxious/Depressed 24(30.8) 26(33.3) 50 (64.1) 5(6.4) 9(11.5) 14(17.9) 8(10.3) 6(7.7) 14(17.9)
Somatic complaints 17(21.8) 15(19.2) 32(41) 3(3.8) 2(2.6) 5(6.4) 17(21.8) 24(30.8) 41(52.6)
Withdrawn 30(38.5) 24(30.8) 54(69.2) 3(3.8) 15(19.2) 18(23.1) 4(5.1) 2(2.6) 6(7.7)
Externalizing Problems 24(30.8) 15(19.2) 39(50) 4(5.1) 12(15.4) 16(20.5) 9(11.5) 14(17.9) 23(29.5)
Attention problems 35(44.9) 34(43.6) 69(88.5) 1(1.3) 4(5.1) 5(6.4) 1(1.3) 3(3.8) 4(5.1)
Aggressive behavior 28(35.9) 32(41) 60(76.9) 8(10.3) 9(11.5) 17(21.8) 1(1.3) 0(0) 1(1.3)
Total 17(21.8) 10(12.8) 27(34.6) 2(2.6) 3(3.8) 5(6.4) 18(23.1) 28(35.9) 46(59)
CBCL(6–18)- TRF
Internalizing Problems 96(27.6) 113(32.5) 209(60.1) 9(2.6) 21(6) 30(8.6) 64(18.4) 45(12.9) 109(31.3)
Anxious/Depressed 115(33) 138(39.7) 253(72.7) 18(5.2) 21(6) 39(11.2) 36(10.3) 20(5.7) 56(16.1)
Withdrawn/depressed 139(39.9) 150(43.1) 289(83) 22(6.3) 20(5.7) 42(12.1) 8(2.3) 9(2.6) 17(4.9)
Somatic complaints 144(41.4) 162(46.6) 306(87.9) 22(6.3) 13(3.7) 35(10.1) 3(0.9) 4(1.1) 7(2)
Externalizing Problems 113(32.5) 104(29.9) 217(62.4) 15(4.3) 17(4.9) 32(9.2) 41(11.8) 58(16.7) 99(28.4)
Rule-breaking 131(37.6) 121(34.8) 252(72.4) 11(3.2) 23(6.6) 34(9.8) 27(7.8) 35(10.1) 62(17.8)
Aggressive behavior 133(38.2) 140(40.2) 273(78.4) 20(5.7) 17(4.9) 37(10.6) 16(4.6) 22(6.3) 38(10.9)
Social problems 115(33) 126(36.2) 241(69.3) 17(4.9) 21(6) 38(10.9) 37(10.6) 32(9.2) 69(19.8)
Thought problems 115(33) 123(35.3) 238(68.4) 16(4.6) 16(4.6) 32(9.2) 38(10.9) 40(11.5) 78(22.4)
Attention problems 164(47.1) 160(46) 324(93.1) 3(0.9) 11(3.2) 14(4) 2(0.6) 8(2.3) 10(2.9)
Total Problems 112(32.2) 110(31.6) 222(63.8) 20(5.7) 22(6.3) 42(12.1) 37(10.6) 47(13.5) 84(24.1)
https://doi.org/10.1371/journal.pone.0278719.t002

Fig 1. Clinical Ranges of males and females aged 4–6 years on CBCL- CTRF. ER = Emotionally reactive, Anx/
Dep = Anxious/Depressed, Som = Somatic complaints, Withd = Withdrawn, Att = Attention problems,
Agg = Aggressive, Int = Internal problems, Ext = External problems, Tot = Total problems.
https://doi.org/10.1371/journal.pone.0278719.g001

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PLOS ONE Behavioral problems and Social-emotional competence

Fig 2. Clinical Ranges of males and females aged 6–8 years on CBCL- TRF. Anx/Dep = Anxious/Depressed,
Som = Somatic complaints, Withd = Withdrawn, Soc = Social problems, Though = Thought problems, Att = Attention
problems, Rulbr = Rule breaking, Agg = Aggressive, Int = Internal problems, Ext = External problems, Tot = Total
problems.
https://doi.org/10.1371/journal.pone.0278719.g002

On the other hand, females were reported as having higher abnormal (borderline and clini-
cal) in both overall externalizing (21.6%) and total problem scores (19.8%). Females were also
reported to have higher abnormal ratings(borderline and clinical) in rule breaking (16.7%),
aggressive (11.2%), thought (16.1%), and attention problems (5.5%) than males.
The Table 3 and show the mean differences in the scores of study variables based on child
gender, and age. Only significant mean difference is found in internalizing problems, where
males have significantly higher internalizing problems than females. Table 4 represents the
mean differences between the age groups with Post hoc analyses (LSD). Age group 1 (4 years
+ age) have more internalizing problems than older children. For externalizing problems, chil-
dren with age range 5–5.11 years have significantly high mean scores, 5+ aged children have
more externalizing problems than 6 to 7+ age group. Furthermore, post hoc analysis reveal
that younger children have more behavioral problems than the older sample. Along with
behavioral problems these children have good social emotional competency and with age the
scores on social emotional competence decrease.

Table 3. Comparison between Males (n = 206) and Females (n = 220) on internalizing, externalizing and social emotional competence (N = 426).
Scales Males Females 95% CI Cohen’s
M SD M SD t (424) p LL UL d
IP 58.47 13.00 56.04 12.23 1.98 .047 .02 4.83 0.19
EP 56.82 10.52 58.18 10.90 -1.31 .191 -3.40 .68 0.12
TP 56.90 13.59 58.19 12.59 -1.01 .312 -3.77 1.21 0.09
SEDA 21.93 2.42 22.20 2.47 -1.13 .259 -.73 .198 0.11

IP = internalizing problems, EP = externalizing problems, TP = total behavioral problems. Cohen (1969) [27] classified effect of 0.2 as small, 0.5 as medium, and 0.8 or
higher as large.

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PLOS ONE Behavioral problems and Social-emotional competence

Table 4. Difference among age groups on study variables (N = 426).

Age group 1 Age group 2 Age group 3 Age group 4
(4–4.11) (5–5.11) (n = 103) (6–6.11) (7–8)
(n = 26) (n = 128) (n = 169)
Variables M SD M SD M SD M SD F P ηp2 Post hoc Analysis
IP 63.54 9.709 63.30 12.295 56.32 12.830 53.21 11.364 17.856 .000 0.11 1>3, >4; 2>3, >4; 3>4
EP 58.46 7.829 61.01 10.312 58.33 11.228 54.64 10.286 8.404 .000 0.05 2>3, >4
TP 63.42 11.243 63.32 13.253 56.91 13.707 53.65 11.146 14.850 .000 0.09 1>3, >4; 2>3, >4; 3>4
SEDA 23.08 1.262 21.84 2.656 21.59 2.874 22.40 1.989 4.510 .004 0.03 1>2, >3; 2<4; 3<4

IP = internalizing problems, EP = externalizing problems, TP = total behavioral problems. df = 3; ηp2 = Partial eta squared values are suggestive of significant effect size.
Cohen (1969) [27] classified effect of 0.2 as small, 0.5 as medium, and 0.8 or higher as large.

https://doi.org/10.1371/journal.pone.0278719.t004

Social emotional competence and behavioral problems

Tables 5 and 6 present the significant association between SEC and behavioral problems.
Child’s higher social emotional competence shows significantly lower level of internalizing
and externalizing problems. The multiple linear regression analysis also reveals the impact of
behavioral problems on social emotional competence of the children. Observing the findings,
it is concluded that behavioural problems together accounts for 16.8% of variance in social
emotional competence, with a significant F ratio (R2 = .028, F(2,423) = 6.17, p = .002). The
behavioural problems are significant negative predictor of SEC in children whereas, externaliz-
ing behavioural problems emerge as stronger negative predictor with Beta value (B = -.034, β =
-.150, p = .068) indicate that one unit increase in externalizing behavioral problems will result
in .34 units decrease in SEC.

Discussion
The present study was conducted with the primary goal of assessing behavioral problems and
its association with social emotional competence in young school children between 4 and 8
years. Findings related to behavioral problems among children revealed alarming borderline
and clinical ranges on CBCL scale. The study shows that 41.5% of all children were categorized
as “abnormal” as in borderline and clinical ranges, with higher internalizing problems (45.1%)
than externalizing problems (39.9%). The prevalence of total problems (41.5%) is similar to
the earlier preschool and school children studies conducted in Pakistan such as preschoolers
(46.5%, assessed with CBCL) [19] and school children (34.4%, assessed with SDQ) [18] and
also to US national survey (41%) [9]. The prevalence was higher than in Norway (7.1%,
assessed through SDQ) and Turkey (11.9%, assessed through CBCL) [31]. The differences
could be partly explained by the different measurement tools, income levels or varied cultural
representations of behavioral and emotional problems in different countries or to the teacher
reports, which are considered pervasive in education research and have considerable potential
as child assessments [32,33].

Table 5. Bivariate correlations between social emotional competence and internalizing, externalizing problems.
Variables Internalizing Problems Externalizing Problems
Social emotional competence -.144** -.168**

** = p < 0.001.

https://doi.org/10.1371/journal.pone.0278719.t005

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PLOS ONE Behavioral problems and Social-emotional competence

Table 6. Multiple linear regression analysis of associations between SEC and Externalizing and internalizing problems.
Variables B SE Β p-Value R2 F (2, 423)
Constant (SEC) 24.28 .641 .000 .028 6.171**
Internalizing problems -.004 .016 -.022 .785
Externalizing problems -.034 .019 -.150 .068

B = “unstandardized regression coefficient”; SE = “Standard error; β = “Standardized regression coefficient”; p-value = “level of significance;
*** = p < 0.000;
** = p < 0.01;
* = p < 0.05.

https://doi.org/10.1371/journal.pone.0278719.t006

Numerous studies have found age and gender differences in the severity and frequency of
children’s behavioral problems. However, these observations are rather inconsistent [31,34].
Our study found that females had more externalizing problems such as rule breaking, aggres-
sion, thought, and attention problems. While among males, internalizing problems were more
common and severe such as anxiety or depression, withdrawn, and somatic problems. It is also
worth noting that younger children had overall more behavioral problems than older children.
Internalizing problems are more prevalent than externalizing problems in younger children.
Furthermore, there is a strong association found between low family income and children’s
behavioral problems as consistent in previous studies [18,19].
There are several factors that contribute to these findings with reference to Pakistan. Firstly,
child development differs across genders in terms of cognitive, emotional, and social aspects
[35,36]. Second, differences in problems may reflect real behavioral differences caused by
child-rearing practices that may include social and environmental factors as well as gender
role attribution. In Pakistan, trends of gender norms are changing; females are now expected
to perform and excel in academia and to represent themselves in society autonomously,
instead of limiting to household chores and being dependent on male figures. According to a
recent survey in Pakistan, 53% parents support and desire their daughters working [37], indi-
cating that gender related social roles are shifting.
The findings further revealed that the frequency of borderline and clinical behavioral prob-
lems on CBCL was quite high in young children. Since the data is collected in Covid-19 pan-
demic, where schooling, limited social activities, and no outside play rules have already
disrupted daily life for school children. These restrictions may have increased children’s behav-
ioral problems. Recent studies have also reflected an increase in emotional and behavioral
problems in school aged children around the globe especially during pandemic [21,38].
Another objective of the study was to observe the association between SEC and behavioral
problems. Our findings revealed that there is a significant negative correlation between social
emotional competence and internalizing and externalizing problems. Children who lack in
SEC have more behavioral problems. This suggests immediate need to plan social emotional
learning programs at school level to teach emotional understanding, self management, proso-
cial behaviors, and resilience which may help children to manage their internalizing and exter-
nalizing symptoms. Various programs such as PATHS, FRIENDS and Coping Power have
established its efficacy in building resilience and reducing behavioral and emotional concerns
in children [39–41]. However, it is recommended to include these programs in school curricu-
lums for Pakistani children.
The strength of this study is based on representation of community sample based on cluster
sampling that is adequately powered to estimate prevalence of behavioral problems and to

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PLOS ONE Behavioral problems and Social-emotional competence

make study generalizable. The assessment was done using the formally adapted and locally val-
idated tool of CBCL, which is an internationally established measure.
The research evidence on emotional and behavior problems of young children in Pakistan is
scarce. Previous studies’ have focused more on parents’ reports and older children. In Pakistan,
the behavior problems of young school children have not been studied for this age group. The
present study is unique in this regard because it used teacher reports and sample represented
public school’s children from low income group as recommended in a recent telephonic survey
[18]. Moreover, results also showed significant abnormal (borderline and clinical) markers in
young children, which further required immediate attention and intervention plans at school
levels. Studies have [7] established that mental health problems manifest at an early age could
endure into adulthood, putting additional strain on the individual, family, friends, and the
healthcare system. Therefore, early interventions play a critical role in their development [24].
In our study, there is noticeable correlation found between child’s social emotional compe-
tence and behavioral problems. Children who have better social emotional competence levels
have showed lower levels of internalizing and externalizing problems. Particularly, children
with high levels of externalizing problems predict low social emotional competence than inter-
nalizing problems. Externalizing problems are easily observable and noticed by teachers in the
classroom environment such as rule breaking, aggressive behavior and hyperactivity and these
problems are related with impulsiveness, lack of self control, emotional knowledge and under-
standing and interpersonal skills.
Additionally, externalizing problems were found strongly related to social emotional com-
petence than internalizing problems in our findings. The possible reason may be related to
emotional expression of the child which varies across cultures. In Asian culture, child’s emo-
tional expression varied with familial and environment context [42]. Pakistani children experi-
ence difficulty in emotional understanding and regulation as evidenced in recent research
[39,40]. Due to lack of adequate emotional management, children may express depressive and
somatic complaints as externalizing behaviors such as aggression, disobedience and defiance,
which are easily observable and noticeable in child’s behavior in the school environment. Fur-
thermore, younger children showed better social emotional competence than older children.
These findings can be better explained with the concept of children’s emotional understanding
and development concepts. With growing age, complexity of emotions increased and children
are required to attach meanings to emotion, whereas in preschool age, children are developing
their ability to regulate and learn emotional expressions without struggling with emotional
masking [43–45].Thus, older children may need social emotional skills training to learn com-
plex emotions and emotional regulation with reference to environment, whereas, younger
children may need basic lessons of emotional recognition, labeling and knowledge as recom-
mended in previous research [39].

Limitations and recommendations

The cross-sectional study collected data from public sector schools in Islamabad metropolitan
area. Therefore, the generalizability of findings of present study are only for public sector
schools. In future work, to increase reliability, data from private schools can be obtained using
both parent and self-report measures (where applicable). Later age groups 8–16 years may also
be included to perform comparative analysis and predict developmental progression of behav-
ioral problems. Multi-informant data sets with more demographic information shall provide
better understanding of cultural factors of behavioral problems. In addition, a nationwide
study is suggested to conduct to get more adequate prevalence estimates for Pakistani children.
As emotional and behavioral problems in young childhood are likely to persist in adulthood,

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PLOS ONE Behavioral problems and Social-emotional competence

early identification and assessment would help teachers, clinicians, counselors and parents to
take better steps in devising management plans.

Conclusion
We examined the estimates of behavioral problems in young school children from public
schools in Islamabad. As a result, we found alarming frequencies of borderline and clinical
ranges of internalizing and externalizing problems and gender differences.
In females, the problem of rule breaking and thought problems in young childhood may be
associated with occurrence of externalizing problems such as conduct disorders and disobedi-
ence. Such problems in females will be seen as severe stigmatization in our culture.
For males, increased levels of anxiousness, depressed characteristics and emotionally reac-
tivity may be associated with internalizing and emotional problems which is also consistent
with the cultural representation of males’ behavior. However, it may lead to more confusion
and lack of self awareness.
We conclude that it is necessary for clinicians and teachers to consider the background of
behavioral problems at school age and take immediate preventive means to teach coping strate-
gies such as universal social emotional learning programs or targeted interventions. Furthermore,
the development of screening system for early intervention is required for school-aged children.

Acknowledgments
We would like to thank all the teachers and schools’ administration for their cooperation in
this research and Federal Directorate Education Commission, Islamabad.

Author Contributions
Conceptualization: Arooj Najmussaqib, Asia Mushtaq.
Data curation: Arooj Najmussaqib.
Formal analysis: Arooj Najmussaqib, Asia Mushtaq.
Investigation: Arooj Najmussaqib.
Methodology: Arooj Najmussaqib, Asia Mushtaq.
Project administration: Arooj Najmussaqib.
Resources: Arooj Najmussaqib.
Supervision: Asia Mushtaq.
Visualization: Arooj Najmussaqib.
Writing – original draft: Arooj Najmussaqib.
Writing – review & editing: Asia Mushtaq.

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