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Impact of alexithymia, speech problems and parental emotion recognition on internalizing and externalizing problems in preschoolers
Alexithymia and psychopathology in preschoolers
https://orcid.org/0000-0002-8414-2895
Jarvers Irina Conceptualization Data curation Formal analysis Investigation Methodology Project administration Software Supervision Visualization Writing – original draft 1 *
https://orcid.org/0009-0005-5680-3659
Kormann Eva Conceptualization Data curation Investigation Methodology Validation Writing – review & editing 2
Schleicher Daniel Conceptualization Methodology Validation Writing – review & editing 1
Ecker Angelika Conceptualization Methodology Validation Writing – review & editing 1
https://orcid.org/0000-0003-3925-7615
Kandsperger Stephanie Conceptualization Methodology Validation Writing – review & editing 1
Brunner Romuald Conceptualization Supervision Validation Writing – review & editing 1
1 Department of Child and Adolescent Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany
2 Institute of Interactive Systems and Data Science, Graz University of Technology, Graz, Austria
Meng Runtang Editor
Hangzhou Normal University, CHINA
Competing Interests: The authors have declared that no competing interests exist.

* E-mail: irina.jarvers@ukr.de
10 9 2024
2024
19 9 e031024426 4 2024
28 8 2024
© 2024 Jarvers et al
2024
Jarvers et al
https://creativecommons.org/licenses/by/4.0/ 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.

Background

Alexithymia, characterized by difficulty identifying and describing emotions and an externally oriented thinking style, is a personality trait linked to various mental health issues. Despite its recognized importance, research on alexithymia in early childhood is sparse. This study addresses this gap by investigating alexithymia in preschool-aged children and its correlation with psychopathology, along with parental alexithymia.

Methods

Data were analyzed from 174 parents of preschoolers aged 3 to 6, including 27 children in an interdisciplinary intervention program, all of whom attended regular preschools. Parents filled out online questionnaires assessing their children’s alexithymia (Perth Alexithymia Questionnaire–Parent Report) and psychopathology (Strengths and Difficulties Questionnaire), as well as their own alexithymia (Perth Alexithymia Questionnaire) and emotion recognition (Reading Mind in the Eyes Test). Linear multivariable regressions were computed to predict child psychopathology based on both child and parental alexithymia.

Results

Preschool children’s alexithymia could be predicted by their parents’ alexithymia and parents’ emotion recognition skills. Internalizing symptomatology could be predicted by overall child alexithymia, whereas externalizing symptomatology was predicted by difficulties describing negative feelings only. Parental alexithymia was linked to both child alexithymia and psychopathology.

Conclusions

The findings provide first evidence of the importance of alexithymia as a possible risk factor in early childhood and contribute to understanding the presentation and role of alexithymia. This could inform future research aimed at investigating the causes, prevention, and intervention strategies for psychopathology in children.

The author(s) received no specific funding for this work. Data AvailabilityThe data that support the findings of this study are openly available from the Open Science Framework (OSF) database at https://osf.io/kzgjn/?view_only=56619072bcb642dc898ad4438dafe7ac. A doi will be provided once the data has been set to public after peer-review.
Data Availability

The data that support the findings of this study are openly available from the Open Science Framework (OSF) database at https://osf.io/kzgjn/?view_only=56619072bcb642dc898ad4438dafe7ac. A doi will be provided once the data has been set to public after peer-review.
==== Body
pmcIntroduction

Mental health issues represent a significant global concern, ranking among the leading causes of mortality worldwide [1]. Among affected demographics, children and adolescents stand out as particularly vulnerable, experiencing mental health disorders at alarming rates, with prevalence rates reaching up to 13.40% [2]. Recent research indicates an increasing prevalence in this population [3], exacerbated by the COVID-19 pandemic. Longitudinal studies consistently highlight the critical link between emotional and behavioral challenges in early childhood and the manifestation of mental health difficulties in adolescence [4]. These adolescent mental health issues often persist into adulthood [5], underscoring the enduring impact of early-life struggles on long-term mental well-being [6]. Given the predictive nature of early childhood mental health challenges and their widespread occurrence, it is imperative to examine potential risk factors. Understanding these factors is essential for informing prevention and intervention strategies aimed at mitigating the burden of mental health disorders across the lifespan.

In recent years, alexithymia—characterized by difficulties in identifying and describing one’s own emotions, coupled with an externally oriented thinking style [7, 8]—has garnered increasing attention as a risk factor influencing mental health outcomes [9]. Alexithymia profoundly impacts various psychiatric disorders during both adolescence and adulthood, including eating disorders [10], depression [11], and substance abuse [12]. Longitudinal investigations have underscored alexithymia’s role as a broad-spectrum risk factor for overall psychopathology in adolescence [13].

While much of the existing research has focused on adults or school-aged children who can self-report their alexithymia levels [13, 14], it is imperative to extend this inquiry to early childhood. Several theories attempt to explain the relationship between alexithymia and psychopathology. The vulnerability hypothesis posits that alexithymia constitutes a risk factor for developing of mental health problems [11], while the reactivity hypothesis postulates that alexithymia is a consequence of psychopathology [11]. To date, few studies involving preschool children have investigated parental alexithymia [15–17], identifying negative correlations between parental alexithymia and preschool children’s emotional skills [15] and positive correlations with psychopathology in toddlers [16]. However, no scientific studies have examined alexithymia in preschool children and its associations with psychopathology. Identifying alexithymia and its potential links to psychopathology in preschool children, before mental health conditions have fully manifested, might provide additional support for the vulnerability hypothesis.

During early childhood, caregivers (mainly parents) and teachers serve as primary informants regarding children’s mental health and alexithymia, given young children’s limited linguistic and introspective capacities for self-reporting [14]. However, it is essential to acknowledge that caregiver reports may be influenced by factors such as the caregivers’ own challenges with emotion recognition [18] or their levels of alexithymia [15–17]. Caregivers’ struggles to identify and interpret their child’s emotions, particularly if they also experience difficulties in recognizing and expressing their own emotions, can compromise the accurate assessment of alexithymia in the child. Previous research indicates that alexithymia in parents is linked to diminished emotional skills in their children and can lead to underestimation of the child’s emotional abilities. [15]. This suggests that parents with higher levels of alexithymia may provide less precise assessments of their child’s emotional skills, even when their children already exhibit reduced emotional performance. Although parental assessments of psychopathology in preschool children have demonstrated high reliability [19, 20], the presence of alexithymia and variations in emotion recognition skills among parents may influence their evaluations of their children’s emotional skills. To mitigate this issue, it is essential to assess parental alexithymia and emotion recognition skills systematically and include them as covariates when investigating parent-reported child alexithymia.

Our study aims to fill the gap of alexithymia research in preschool children by conducting an online survey for parents, assessing parent-reported alexithymia levels and psychopathology in children aged 3 to 6 years. Through this investigation, we seek to elucidate the early emergence of alexithymia as a potential precursor to later mental health challenges, thereby informing targeted interventions and prevention strategies. Additionally, our study aims to investigate the influence of parents’ emotion recognition skills and alexithymia on children’s alexithymia and psychopathology. To achieve this, we queried parents on their levels of alexithymia and emotion recognition skills, their children’s participation in early interdisciplinary intervention programs (IIP), and demographic details. IIPs cater to children from birth until school entry who are either impacted by or at risk of developing physical, intellectual, or mental disabilities. A significant portion of these children exhibit emotional or behavioral challenges, thus increasing the likelihood of displaying psychopathological symptoms, which in turn increases variance in the sample.

We hypothesized a significant correlation between parent-reported alexithymia levels in preschool-aged children and the alexithymia levels reported by their parents. Furthermore, we anticipated associations between both parental and child alexithymia and parent-reported psychopathological symptoms in children. Identifying these associations would underscore the pivotal role of early emotional comprehension in children’s mental health and provide valuable insights for developing targeted early intervention strategies.

Materials and methods

The study was approved by the Ethics Committee of the University of Regensburg (ID: 22-2878-101) and preregistered in the German Clinical Trials Register (DRKS; DRKS00029046). Participants were digitally provided with information on the study purpose, inclusion and exclusion criteria, and anonymous data collection and storage. Following this information, participants provided digital, informed consent by specifically ticking boxes indicating their agreement to participate, their agreement to anonymous data evaluation and that they are aware of the voluntary nature of the study. The recruitment period for this study spanned from 25/05/2022 to 15/01/2023.

Participants

The desired sample size was determined via an a-priori power analysis in G*Power [21] for a multiple linear regression predicting children’s psychopathology from 10 predictors. The correlation with alexithymia is reported at .62 for both anxiety and depression by Weissman et al. [13]. Brown et al. [14] found correlations between parent-reported alexithymia and psychopathology (measured via the Strengths and Difficulties Questionnaire), ranging between .23 and .30. Based on these effect sizes, the association of alexithymia with psychopathology is estimated to be of approximately medium size. To detect a medium effect of R2 = .13 [22] at a power of 80.0% in a multiple linear regression with ten predictors and α = 5%, a sample of 118 participants is necessary.

A total of 227 parents were recruited via local preschools and interdisciplinary intervention centers (“Frühförderstellen”) in northeastern Bavaria, Germany. Out of these, n = 53 terminated the survey prematurely, resulting in a final sample of N = 174. Inclusion criteria were being the primary caregiver of a child between 3 and 6 years of age, children’s regular preschool attendance, the absence of intellectual disability, and adequate comprehension of the German language. At the time of the survey, children had been attending preschool for an average of 1.22 years (SD = 0.97) and were on average 4.54 years old (SD = 0.97; 50.60% female). About 7.00% were bilingual and 66.10% had siblings. Interdisciplinary intervention program participation applied to 15.50% and 10.30% had speech problems (language delays were noted during the last routine examination by a medical doctor). Parents were between 22 and 44 years of age (M = 34.48, SD = 4.82; 75.30% female) and the majority was married (80.50%). The level of education was used as an approximation of socio-economic status and 31.60% had a university degree, 21.80% completed a-levels, 23.00% completed training school (Berufsschule), 13.20% completed 10 years of school education (Realschule), 9.80% completed 9 years of school education (Hauptschule), and 0.60% did not finish school. All parents had German nationality and spoke fluent German.

Procedure

Flyers and postings were distributed at preschools and interdisciplinary intervention centers in northeastern Bavaria, Germany, including detailed information about the study and a QR code that parents could scan to access the online survey, which was programmed in LimeSurvey (Version 3.17.0, http://limesurvey.org). At the beginning of the survey, participants were briefed on the study’s purpose and assured of voluntary participation, with the option to stop at any time or fully withdraw, resulting in the automatic deletion of their data. Details on anonymous data collection and storage were provided. Parents explicitly confirmed their first-time participation, their child’s non-inclusion in previous study reports, their child’s attendance at a standard preschool during data collection, and the absence of an intellectual disability diagnosis. Subsequently, they provided informed consent to participate. Initially, demographic information regarding the parent (age, sex, nationality, education) and the child (age, sex, participation in an IIP, speech problems) was collected. Following this, parents completed questionnaires on alexithymia, emotion recognition, and child psychopathology. Finally, they were directed to a separate survey where they had the option to provide their email address for compensation in the form of a 10-euro voucher. Participants were assured that their responses could not be linked to the provided email address.

Material

Perth Alexithymia Questionnaire (PAQ)

Questionnaire measures currently stand as the most widespread and reliable assessments of alexithymia across all age groups. The PAQ is a recently developed self-report measure designed to assess alexithymic traits in adults while addressing shortcomings of previous questionnaires by incorporating separate items for negative and positive feelings [23]. Participants rate 24 items on a 7-point Likert scale and subscales include "externally oriented thinking" (EOT) for attention to one’s own feelings, "difficulty identifying feelings" (DIF), and "difficulty describing feelings" (DDF) for negative and positive feelings, respectively. Multiple composite scores can be derived, including a total alexithymia score and general difficulties in appraisal. The PAQ demonstrates good internal consistency (Cronbach’s α = .87 to .96) and confirms its proposed factor structure [23, 24]. In this study, the German version by Kaemmerer et al. [25] was utilized, showing high reliability in the present sample of parents (Cronbach’s α = .97). The PAQ was chosen for its strong psychometric properties and its ability to differentiate between negative and positive feelings, setting it apart from other widely used alexithymia measures.

The German version of the PAQ [25] was adapted into a self-report version for children (PAQ-C) by Jarvers et al. [26], with adjustments made to language for child appropriateness. The PAQ-C retains the original item sequence and scoring instructions from the adult version. Validation for the PAQ-C is ongoing (Jarvers et al., 2021). In this study, the PAQ-C items were rephrased into third person perspective to create a parent-report version (PAQ-P). Cronbach’s α for the total score was .96 in this study, with α ranging between .83 and .94 for subscales.

Strengths and Difficulties Questionnaire (SDQ)

The SDQ is a widely used screening tool for assessing emotional and behavioral difficulties in children and adolescents [27]. It comprises 25 items rated on a 3-point scale. The instrument includes five subscales: emotional problems, conduct problems, hyperactivity, peer problems, and prosocial behavior. A total difficulties score is obtained by summing all subscale scores except prosocial behavior. The emotional problems and peer problems scales can be combined into an "internalizing" scale, while the conduct problems and hyperactivity scales can form an "externalizing" scale [20]. Internalizing refers to problems directed towards the inside (such as anxiety, depression, somatic complaints) and externalizing refers to problems directed towards the outside (such as aggression, hyperactivity, and oppositional defiance) [28]. For both scales values above 7 are considered at risk and values above 9 are considered critical. The SDQ demonstrates good internal consistency and discriminates well between clinical and non-clinical groups [29]. In this study, appropriate versions were administered automatically via LimeSurvey, with age-specific adaptations applied.

The Reading the Mind in the Eyes Test (RMET)

The Reading the Mind in the Eyes Test (RMET) was initially developed as a measure of Theory of Mind (ToM) and participants are presented with photographs of eye regions and asked to infer mental and emotional states [30]. Although widely used in research on social cognition, recent discussions suggest it may primarily assess facial emotion recognition rather than ToM [31]. The RMET comprises 36 test items and one practice item, each with four forced-choice answer options. Test scores are calculated based on the number of correctly identified items. The original version has demonstrated some psychometric weaknesses, leading to the development of shorter forms. This study utilized a 10-item short version developed by Olderbak et al. [32], which showed improved homogeneity compared to the full version.

Statistical analysis

Statistical analyses were conducted using the R statistical package, version 4.0.2 [33] and SPSS 28 [34]. Initially, correlations between children’s and parental alexithymia were examined. Next, the impact of demographic variables such as age, sex, education, IIP participation, and speech problems on children’s alexithymia and internalizing and externalizing psychopathology was assessed using Mann-Whitney U tests and bivariate correlations. Correlational analyses were also employed to investigate whether specific subscores of child alexithymia were relevant to internalizing and externalizing symptomatology. Finally, linear multivariable regressions were conducted to identify significant predictors for a) children’s alexithymia and b) children’s internalizing and externalizing symptomatology. The predictors included in each regression model were parental alexithymia, parental emotion recognition, and parental care hours per day, considering that parents’ reports may be influenced by the amount of time spent with their child. Multiple comparisons were controlled for using the False Discovery Rate (FDR, [35]) and alpha-level was set to 0.05.

Results

An overview of scores for parental and child variables across both groups (IIP and no IIP) and for the total sample is depicted in Table 1. Group differences between children attending an IIP and those who did not were present in parental education (U = 1455.00, p = .026, r = .13), internalizing and externalizing symptomatology (U = 961.00–1202.50, p < .001, r = .24 - .32), and parental emotion recognition skills (U = 838.50, p < .001, r = .35). Overall, children attending an IIP showed more psychopathology and had parents with lower education and better emotion recognition skills. All other variables were non-significant (p > .05). Across both groups, 16.7% of children were at risk and 25.4% of children had critical scores in internalizing psychopathology. For externalizing psychopathology, 22.5% of children were at risk and 38.2% had critical scores. There was a significant positive correlation between children’s and parents’ alexithymia total scores (r = .37, p < .001). The same applied to subscores (p < .001). See Fig 1 for a graphical depiction of alexithymia scores.

10.1371/journal.pone.0310244.g001 Fig 1 Overview of child and parental alexithymia total score.

PAQ-P = Perth Alexithymia Questionnaire Parent Report, PAQ = Perth Alexithymia Questionnaire.

10.1371/journal.pone.0310244.t001 Table 1 Sample characteristics.

Variable	IIP Sample M (SD)	Non IIP Sample M (SD)	Total Sample M (SD)	Range	
Parent					
    Age	35.44 (5.20)	34.31 (4.76)	34.48 (4.82)	22–44	
    Care time	9.54 (4.47)	8.66 (4.58)	8.78 (4.55)	2–20	
    (hours per day)	
    Alexithymia	54.07 (30.83)	57.01 (30.23)	56.65 (30.19)	24–150	
    (PAQ)	
    Emotion	7.11 (1.48)	4.60 (2.54)	5.02 (2.58)	0–10	
    recognition	
    (RMET)	
Child					
    Age	4.85 (0.91)	4.51 (0.96)	4.55 (0.96)	3–6	
    Alexithymia	72.48 (31.45)	72.29 (25.40)	72.05 (26.51)	24–132	
    (PAQ-P)	
    Internalizing	8.00 (3.48)	5.74 (2.94)	6.06 (3.15)	0–15	
    (SDQ)	
    Externalizing	10.18 (4.01)	6.42 (3.41)	7.03 (3.74)	0–18	
    (SDQ)	
Note. PAQ = Perth Alexithymia Questionnaire, RMET = Reading the Mind in the Eyes Test, PAQ-P = Perth Alexithymia Questionnaire Parent Report, SDQ = Strengths and Difficulties Questionnaire.

Demographic variables

Children’s alexithymia scores (measured by the PAQ-P) did not differ significantly between males and females (U = 3512.00, p = .755, r = .02), whether the children participated in an IIP (U = 1881.00, p = .877, r = .01), or whether they had speech problems (U = 1155.00, p = .281, r = .08). However, fathers reported significantly higher alexithymia scores for their children (M = 82.00, SD = 18.7) compared to mothers’ reports (M = 68.80, SD = 27.90; U = 1926.00, p = .006, r = .21). Correlational analyses revealed a significant negative correlation between child alexithymia and parental age (r = -.19, p < .001) and a significant positive correlation with parental education (r = .11, p = .048).

Children’s internalizing scores (measured by the SDQ) did not differ significantly between boys and girls (U = 3661.00, p = .806, r = .02) or based on the sex of the parent (U = 2704.0, p = .747, r = .02). However, children with speech problems (U = 823.0, p = .004, r = .22; Speechyes: M = 8.1, SD = 2.9, Speechno: M = 5.8, SD = 3.1) and those participating in an IIP (U = 1202.0, p = .001, r = .24, see Table 1) had significantly higher internalizing scores compared to those who did not. Correlational analyses revealed a significant positive correlation of children’s internalizing scores with child age (r = .24, p < .001) and a significant negative correlation with parental age (r = -.15, p = .006).

Children’s externalizing scores (measured by the SDQ) did not differ significantly based on the sex of the parent (U = 2338.0, p = .106, r = .12). However, significant differences were found based on child sex (U = 2825.0, p = .005, r = .21; Boys: M = 7.8, SD = 3.8; Girls: M = 6.3, SD = 3.6), IIP participation (U = 961.0, p < .001, r = .32, see Table 1) and speech problems (U = 722.5, p < .001, r = .26; Speechyes: M = 9.8, SD = 3.7; Speechno: M = 6.7, SD = 3.6). Overall, boys, children participating in IIP, and children with speech problems showed higher externalizing scores. Parental age (r = -.22, p < .001) and parental education (r = - .14, p = .015) were significantly negatively correlated with externalizing scores.

Predicting preschool children’s alexithymia

To predict preschool children’s alexithymia scores, a linear multivariable regression model was computed that incorporated demographic variables such as child sex, parent sex, parental age, and parental education. The model was significant (F(7, 169) = 11.84, p < .001) and accounted for 33.80% of the variance in children’s alexithymia. The details of the predictors in this regression model are presented in Table 2.

10.1371/journal.pone.0310244.t002 Table 2 Results of the linear regression model predicting children’s alexithymia.

Dependent Variable	Predictor	B	SE	β	t	p	R2	
Alexithymia (child)	Sex (child)	-1.93	3.51	-0.04	-0.55	0.583	0.34	
Sex (parent)	-0.37	0.40	-0.07	-0.92	0.359		
Age (parent)	0.45	4.41	0.01	0.10	0.918		
Education (parent)	2.47	1.36	0.13	1.82	0.071		
Alexithymia (parent)	0.38	0.07	0.44	5.77	<0.001		
Emotion recognition (parent)	-2.01	0.77	-0.20	-2.60	0.010		
Care hours per day (parent)	-0.43	0.40	-0.07	-1.07	0.286		
Note. Alexithymia was measured using the Perth Alexithymia Questionnaire (original version for parents, parent report version for children). Emotion recognition in parents was assessed using the Reading the Mind in the Eyes Test.

Predicting externalizing and internalizing symptomatology

Two linear multivariable regression models were computed to predict children’s internalizing and externalizing symptomatology. Correlational analyses revealed significant correlations between all subscores of children’s alexithymia and internalizing symptomatology (all p < .002), leading to the inclusion of the total alexithymia score in the model for internalizing symptoms. For externalizing symptomatology, the strongest association was found with difficulties describing negative feelings (r = .23, p < .001), which was included as a predictor. Additional demographic variables included child age, child sex, parental age, parental education, participation in an IIP, and speech problems.

The model predicting internalizing symptomatology was significant (F(10,159) = 10.57, p < .001) and accounted for 39.90% of the variance. Similarly, the model predicting externalizing symptomatology was significant (F(10,159) = 12.79, p < .001) and explained 44.60% of the variance. Detailed information on both models is provided in Table 3. Exploratory analyses using the alexithymia total score as predictor for externalizing symptomatology did not yield child alexithymia as a significant predictor.

10.1371/journal.pone.0310244.t003 Table 3 Results of linear regression models predicting children’s internalizing and externalizing symptomatology.

Dependent Variable	Predictor	B	SE	β	t	p	R 2	
Internalizing symptoms (child)	Sex (child)	0.62	0.41	0.10	1.53	0.127	0.40	
Age (child)	0.99	0.21	0.30	4.64	<0.001		
Alexithymia (child)	0.02	0.01	0.15	2.00	0.047		
Intervention program	-1.54	0.59	-0.18	-2.60	0.010		
Speech problems	1.82	0.72	0.18	2.54	0.012		
Age (parent)	-0.03	0.05	-0.05	-0.72	0.473		
Education (parent)	0.00	0.16	0.00	0.01	0.993		
Alexithymia (parent)	0.03	0.01	0.31	3.91	<0.001		
Emotion recognition (parent)	0.03	0.09	0.02	0.31	0.758		
Care hours per day (parent)	0.09	0.05	0.14	2.04	0.043		
Externalizing symptoms (child)	Sex (child)	-0.54	0.47	-0.07	-1.17	0.245	.45	
Age (child)	0.58	0.24	0.15	2.40	0.018		
Alexithymia (child)	0.05	0.03	0.14	2.04	0.044		
Intervention program	-1.82	0.68	-0.18	-2.67	0.008		
Speech problems	1.22	0.82	0.10	1.48	0.141		
Age (parent)	-0.12	0.05	-0.16	-2.26	0.025		
Education (parent)	-0.30	0.18	-0.11	-1.64	0.104		
Alexithymia (parent)	0.04	0.01	0.31	4.15	<0.001		
Emotion recognition (parent)	0.36	0.10	0.24	3.46	0.001		
Care hours per day (parent)	0.10	0.05	0.12	1.96	0.052		
Note. SDQ (= Strengths and Difficulties Questionnaire) scales were used as outcome variables. Alexithymia was measured using the Perth Alexithymia Questionnaire (original version for parents, parent report version for children). For externalizing symptoms, the difficulties describing negative feelings scale is used. Emotion recognition in parents was assessed using the Reading Mind in the Eye Test.

Both regression analyses were repeated excluding the subgroup of children attending an IIP, and the results consistently showed the same pattern.

Discussion

The present study aimed to investigate the relation between alexithymia in preschool children and their internalizing and externalizing symptomatology. Furthermore, parents’ characteristics were considered as they are the main informants when studying early childhood and have a great influence on development during preschool age. We hypothesized a significant correlation between parent-reported alexithymia levels in preschool-aged children and the alexithymia levels reported by their parents. Additionally, we expected to observe links between both parental and child alexithymia and parent-reported internalizing and externalizing symptomatology in children.

Preschool children’s alexithymia

Most previous studies have not included children of preschool age or have examined young children only in combined samples with older children [13, 36]. Therefore, findings specifically on alexithymia in preschoolers constitute a novelty and illuminate the presentation of alexithymia in early childhood.

As expected, no significant sex differences were observed in alexithymia levels among preschoolers. While higher levels for men compared to women are discussed in adults [37], no theoretical basis suggests sex differences in early childhood. Factors highlighted by Levant et al. [37], i.e., socialization and expectations for men, may become relevant later in life, thus not yet impacting alexithymia levels in early childhood.

No significant association was found between the age of the children and their alexithymia levels. Karukivi and Saarijärvi [38] hypothesized that high alexithymia might be common, particularly in young children, given the ongoing development of emotional skills. However, the present sample was homogeneous regarding the respective life stage of the children, namely preschool. Thus, children may have been experiencing similar challenges in emotional development.

Surprisingly, no significant differences were found in alexithymia between children with and without speech problems. This finding contradicts the assumption that impaired language development plays a significant role in the etiology of alexithymia [39]. Possible explanations could be that the repercussions of language delays might manifest later in life, and children with identified speech delays may already be undergoing interventions.

Interestingly, fathers reported higher levels of alexithymia for their children compared to mothers. While family structures might vary between these informant groups, a reporting bias between fathers and mothers seems more plausible than genuine pronounced differences. Exploring relationship status and daily caregiving hours in relation to the sex of the reporting parent could be valuable in future analyses to clarify this group disparity.

When examining how much variance in children’s alexithymia could be explained by demographic variables, as well as parental alexithymia and emotion recognition, only the latter two factors emerged as significant predictors. Parental alexithymia has been found to correlate with child alexithymia in previous studies [40]. This association may stem from various factors. Firstly, alexithymia has a genetic component, with an estimated heritability of around 30% [41], suggesting a positive correlation between parental and child alexithymia due to shared genetics alone. Furthermore, parenting style, known to be associated with parental alexithymia [42], may mediate the relationship between parental and child alexithymia, warranting further investigation in future studies. Parental emotion recognition likely predicts child alexithymia levels, but it may also affect how parents report on their child’s alexithymia. Parents with lower emotion recognition skills might find it harder to accurately report on their children’s emotional experiences, potentially biasing their responses.

Alexithymia in relation to internalizing problems

In the present study, children’s older age, higher alexithymia, participation in an IIP, speech problems and higher parental alexithymia as well as longer care hours were significant predictors for internalizing symptomatology. Given that data collection occurred in 2022, it is noteworthy to consider the potential influence of the ongoing COVID-19 pandemic on children’s behavior, particularly for older children. In a study by Jarvers et al. [43], which surveyed behavior in preschoolers before, during, and after nationwide lockdowns in Germany, difficulties increased significantly during lockdown measures and persisted afterward. In the current study, conducted approximately a year later, it is possible that older children were more affected by lockdown measures and continue to exhibit more internalizing behavior as a consequence.

No sex difference could be detected regarding internalizing symptomatology, which is in line with previous findings [4]. Similarly, the impact of participation in an IIP and speech problems aligns with prior work: Developmental and medical issues in children have been consistently linked to internalizing behavior [44]. Concerning speech problems, a bidirectional relationship between internalizing problems and language difficulties has been suggested, where problems in communication can cause social withdrawal and vice versa [45].

As expected, child alexithymia (PAQ-P scores) demonstrated significant predictive value, with higher alexithymia scores predicting internalizing behavior. This association has been consistently observed in numerous studies, albeit with older samples [13, 14, 36]. The present findings align with prior research, providing valuable insights into an age group not previously studied on this specific topic. With the inclusion of a preschool sample, the association between alexithymia and internalizing problems has now been demonstrated consistently from early childhood to adulthood.

The association between alexithymia and psychopathology can be examined through different lenses. Hemming et al. [11] delineate several contrasting perspectives on this matter. The vulnerability hypothesis proposes that alexithymia serves as a predisposing factor for the emergence of mental health issues. Conversely, the reactivity hypothesis suggests that alexithymia emerges as a consequence of pre-existing conditions. While the current study’s cross-sectional design constrains its ability to definitively resolve this debate, the discovery of this association in a preschool sample implies that alexithymia is not solely a delayed outcome of internalizing problems. This finding lends support to the vulnerability hypothesis over the reactivity hypothesis.

A further significant predictor of internalizing symptomatology in preschool children was parental alexithymia. Parents reporting higher levels of alexithymia also reported increased internalizing behavior in their children. This is in line with previous work in school-aged children that identified parental alexithymia as a significant predictor for psychopathology [46]. Parental mental health issues are known to increase the risk of similar problems in children [4]. Given that alexithymia is associated with anxiety and depressive disorders in adults [12], highly alexithymic parents may be more susceptible to mental health issues themselves, affecting their children. Additionally, parental alexithymia is linked to parenting styles [42], which in turn can affect children’s internalizing difficulties [47]. However, data on parental mental health and parenting styles were not collected in this study, so any discussion of mediating effects remains speculative.

At first, it may seem surprising that longer care hours are associated with higher internalizing symptomatology in preschool children. However, internalizing problems are often overlooked [48], especially in younger children and prolonged time spent with the child might increase the likelihood of identifying symptoms.

Alexithymia in relation to externalizing problems

In the present study, significant contributors to externalizing symptomatology included children’s older age, higher levels of alexithymia (difficulties describing negative feelings), and participation in an IIP, as well as parents’ younger age, higher alexithymia, and better emotion recognition skills. Similar to internalizing symptomatology, older children may have been more affected by the COVID-19 pandemic compared to younger children who entered preschool later. This also applies to participation in an IIP, as developmental delays have been linked to externalizing symptomatology [49]. Interestingly, child sex did not emerge as a significant predictor, despite previous studies indicating higher externalizing symptomatology in boys [50]. One possible explanation could be that sex differences in externalizing behaviors are often attributed to language delays [51], which were partially accounted for in the model through speech problems and the difficulties describing negative feelings scale of the alexithymia questionnaire.

In contrast to internalizing symptomatology, only the alexithymia facet “difficulties describing negative feelings” was predictive of more parent-reported externalizing symptoms. Challenges in articulating one’s negative emotional states may correlate with feelings of helplessness and anger, potentially leading to overwhelm and externalizing behaviors [52]. Effective communication of emotions, particularly negative ones, is vital in preschoolers for fostering emotion regulation, strongly linked to externalizing issues in this age group [53]. This focus on negative emotions aligns with previous studies utilizing the PAQ [23, 24, 54].

Parental factors, such as younger age, also had an impact on children’s externalizing symptoms in the current sample. Younger parents, who may feel less prepared for parenthood, might resort to harsher parenting due to feelings of being overwhelmed, thereby potentially leading to increased externalizing behaviors in preschoolers [55]. Alternatively, less experience in parenting might influence reporting, with younger parents possibly rating their children’s behavior as more pathological compared to older parents.

Parental alexithymia also demonstrated an effect and may impact children’s externalizing symptomatology in a similar fashion to internalizing symptomatology, notably through parenting styles and parental mental health issues [12, 42].

Finally, enhanced parental emotional recognition skills were linked with elevated externalizing symptomatology in preschool children. The direction of this relationship remains unclear due to the cross-sectional design of the present study; therefore, it is plausible that parents of children exhibiting externalizing symptoms have developed heightened sensitivity towards emotion expressions in order to respond promptly. Alternatively, there could be a reporting bias, wherein parents with superior emotion recognition skills tend to report more externalizing behaviors in their children.

Strengths and limitations

The present study benefited from several significant strengths. Methodological decisions allowed for the examination of an understudied age group regarding alexithymia within a sizable sample exceeding statistical requirements. Additionally, the study controlled for various factors, including subjective (questionnaires) and objective measures (RMET). Furthermore, the utilization of the newly developed PAQ provided a comprehensive assessment of difficulties with positive and negative emotions, as well as excellent psychometric properties.

However, also some limitations of the current study need to be addressed to contextualize its findings. One concern is the representativeness of the sample under investigation. The participants comprised children aged 3 to 6 years attending regular preschools in northeastern Bavaria, Germany. While this might enhance the homogeneity of the sample, it may exclude children who are cared for at home. However, it’s worth noting that in the year 2022, 91.7% of all 3- to 6-year-olds in Germany attended preschool [56], indicating that the majority of children would have been eligible for this study. Future research should investigate alexithymia in preschool-aged children who do not attend preschool. This is important because peer interactions increase during this period, and children interact more with alternative caregivers who may possess resources for emotional knowledge that children not attending preschool may lack [15]. As our sample consists of children in Germany, it is crucial to consider cultural aspects, particularly differences in emotional language and expression across cultures [57]. Nevertheless, previous research on alexithymia and psychopathology suggests similar relationships across countries [58]. An additional aspect that may impact the generalizability of the findings is the slight overrepresentation of individuals with a university degree in our sample. Preschool attendance can be costly, and not all parents in Germany are able to secure a spot for their child, making higher education levels likely in a preschool-attending sample [43].

Several limitations are inherent in the methodology of this study. Despite extensive plausibility checks, determining the accuracy of responses in an anonymous online survey presents a challenge and needs to be considered. Moreover, while the original version of the PAQ shows excellent reliability and validity across several languages [24, 54], and showed excellent reliability in our sample, the adapted version used to assess child alexithymia (the PAQ-P) lacks validation as it was adapted specifically for this study.

Another methodological limitation is that this study relied on only one rater (one parent) and solely utilized questionnaires. However, no reliable objective measures are available to assess alexithymia, no matter the age, and parents have been shown to be reliable informants on child psychopathology [19, 20], especially during preschool age [59]. Additionally, using parent-report questionnaires enhances comparability with many other studies, as research on children’s emotions and behaviors frequently involves surveying only one parent [4, 14, 36].

Finally, our study was a cross-sectional investigation of alexithymia and psychopathology in preschool children. Although it is generally assumed that alexithymia develops early and precedes the onset of mental health problems [60], this study cannot establish causality and only examines the correlational relationship between these variables in children aged 3 to 6. Future longitudinal research is needed to explore the development of alexithymia and psychopathology over time, enabling a better understanding of the directionality of their relationship.

Conclusion

Overall, early childhood, specifically preschool age, has received limited attention in alexithymia research. The present study investigated the relation between alexithymia in preschool children and their internalizing and externalizing symptomatology, considering parental factors like parental alexithymia and parental emotion recognition skills. We found that both child alexithymia and parental alexithymia were significant predictors of internalizing and externalizing psychopathology in preschool children. To the best of our knowledge, this is the first study to explore alexithymia and related concepts exclusively within a preschool sample. These findings offer initial insights into the role of alexithymia as a risk factor in early childhood, providing a basis for future research aimed at understanding the causes, prevention, and intervention strategies for internalizing and externalizing difficulties in children.

The authors would like to thank all parents and children who were part of this study. No funding was received for this study.

10.1371/journal.pone.0310244.r001
Decision Letter 0
Meng Runtang Academic Editor
© 2024 Runtang Meng
2024
Runtang Meng
https://creativecommons.org/licenses/by/4.0/ 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.
Submission Version0
2 Jul 2024

PONE-D-24-15302Impact of alexithymia, speech problems and parental emotion recognition on internalizing and externalizing problems in preschoolersPLOS ONE

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Reviewer #1: The article provides a compelling examination of alexithymia in preschool-aged children, an area that has been scarcely explored in the literature despite its significant implications for mental health. The study addresses a notable gap by investigating the relationship between child and parental alexithymia and its impact on early childhood psychopathology.

The research is well-written, presenting a clear methodology involving data from 174 parents of children aged 3 to 6. The use of validated questionnaires to assess alexithymia and psychopathology in both children and parents is a strong point, as it allows for a robust analysis of the relationships between these variables. The findings highlight the predictive power of parental alexithymia and emotion recognition abilities on child alexithymia, and how these factors relate to internalizing and externalizing symptomatology in children.

Notably, the study underscores the importance of alexithymia as a potential risk factor in early childhood, providing a foundation for future research aimed at understanding its causes, prevention, and intervention strategies for associated psychopathology. This perspective opens new avenues for exploring early intervention techniques and enhancing parental support programs to mitigate the development of mental health issues in children.

The article's limitations are punctually addressed, further strengthening its validity. The authors' thorough discussion of these limitations ensures that the conclusions drawn are well-supported and that the study provides a comprehensive overview of the topic.

Overall, this study is a valuable contribution to the field, offering fresh insights and setting the stage for future research on alexithymia and childhood psychopathology.

Reviewer #2: the article titled Impact of alexithymia, speech problems and parental emotion recognition on

internalizing and externalizing problems in preschoolers is an innovative topic and difficult to conduct for preschoolers too. It will be the foundational stone for further related studies.

Reviewer #3: The article presented by the authors aims to fill in the gaps on the topic of alaxithaemia, where research is scarce. The subject is complex, but the author has produced a very detailed and meticulous article. Previous articles have mainly looked at the adult or pre-school age, leaving out early childhood, which turns out to be extremely important and little studied, given the difficulty of the patient. In addition to congratulating the authors for having written an article on a very complex subject, providing data and considerations that are very important for the entire scientific community, I would like to make the following suggestions to improve an article that is already of a very high standard.

The objectives set by the authors have been respected and developed in an appropriate manner, providing an important starting point for future studies. First of all, the entire article should be reviewed in English, as there are redundant terms that can be improved by synonyms, if not grammatical errors that can be easily corrected.

Introduction:

38-44: I would pay more attention to this paragraph, as it is of particular importance for the purpose of the article, I would improve its drafting, including any studies, regarding the identification of "pathology" when caregivers struggle to identify and interpret the child's emotions, identifying possible and viable solutions to remedy this problem.

Study design:

The study design described in the introduction was explained in a clear and simple manner.

Materials and methods:

The flow of data collection, with the criteria used for the study, has been described in an appropriate and thorough manner, there are no corrections to be made as they are meticulous. The statistical data produced are meaningful, clear and easy to understand.

I would suggest an extension of the study court, for future implementation of the study, as it is often and scientifically important.

The material presented for data collection, was well documented, described it impeccably, there are no corrections to be made.

Statistical analysis, well documented, highlighting the strengths and limitations of the study.

Conclusions:

The article is very long, but the importance of the topic justifies the length. All data, results and discussions are well documented. The article is of high scientific importance, a necessary result for the whole scientific community, with the aim of increasing knowledge in a topic that is still little explored. All data and methods used are user-friendly. The authors have presented an article that adheres to appropriate reporting guidelines and community standards for data availability. Applicable standards for study ethics and research integrity are met. The manuscript is well written and I believe it can be accepted for publication. Implementation with a series of case study articles is necessary for the future development of the topic of scientific interest, as I believe it will benefit the entire scientific community.

Reviewer #4: 1. In the abstract of the original article, the details of the materials and methods should be presented separately from the results. This ensures clarity and facilitates understanding of both the procedures employed and the findings obtained.

2. In Table 2 and 3: Maintain consistency in the notation and format of numerical data. The use of zero as an integer and then omitting it elsewhere could cause confusion. Uniformity in the presentation of results.

3. In the final paragraph of the discussion, spaced 9-10, it is noted that authors are cited in a format different from the Vancouver style. Unify the citation style with the rest of the content.

4. The conclusion focuses more on the relevance of the study and its implications for future research, rather than detailing specific findings that address the purpose of the study.

Reviewer #5: Interesting study from the point of view of the mental health of parents and children, however there are some observations that I detail below:

Summary: It is missing to place the study design and briefly the selection criteria. The wording of the statistics used is not understood.

Introduction: Improve the wording by being more precise with what has been found in the review of the scientific evidence, improve the wording of the justification, and should conclude with the objective of the study.

Material and method: Adequately describe the selection criteria, adequately detail the procedural phase, be more precise with the wording of the statistical analysis.

Results: Improve the wording of the interpretation of the results.

Conclusion: Be more precise and objective in the wording.

Reviewer #6: The study presents an important and under-researched area in understanding alexithymia in early childhood and its implications for psychopathology, providing valuable insights into the potential intergenerational transmission of emotional processing difficulties. While the topic is relevant and the research question is well-framed, there are several methodological and interpretative concerns that need to be addressed to strengthen the manuscript.

Major Comments:

Sample Size and Generalizability:

The sample size of 174 parents, including a subgroup of 27 children in an intervention program, raises concerns about the generalizability of the findings. More information on how these participants were selected and how representative they are of the broader population is necessary.

Consider discussing the limitations of the sample size more explicitly and how it might impact the study's conclusions.

Measurement Tools:

The reliance on parent-reported measures (Perth Alexithymia Questionnaire – Parent Report and Strengths and Difficulties Questionnaire) introduces a potential bias. Parents’ perceptions may not accurately reflect the child’s true emotional state or behavior.

It would strengthen the study to include direct assessments of the children, possibly through observational methods or clinician-administered measures.

Intervention Program Group:

The inclusion of 27 children in an interdisciplinary intervention program could introduce confounding variables. The differences between this subgroup and the rest of the sample should be clarified.

An analysis comparing outcomes between children in the intervention program and those not in the program would be beneficial.

Causality and Directionality:

The cross-sectional nature of the study limits the ability to draw causal conclusions. While the study suggests correlations between parental alexithymia, child alexithymia, and psychopathology, it cannot establish causality.

Consider discussing longitudinal designs or other methods that could be used in future research to better understand the causal relationships.

Minor Comments:

Literature Review:

The introduction could benefit from a more thorough review of existing literature on alexithymia in early childhood and its links to psychopathology to provide a stronger foundation for the study.

Clarification of Terms:

Terms such as "internalizing symptomatology" and "externalizing symptomatology" should be clearly defined for readers who may not be familiar with these concepts.

Formatting and Writing:

Ensure consistency in the use of terms and abbreviations throughout the manuscript.

Minor grammatical and typographical errors should be corrected to improve readability.

Conclusion:

While the study addresses a significant gap in the literature and provides preliminary evidence on the role of alexithymia in early childhood, the methodological and interpretative concerns need to be addressed to ensure the findings are robust and generalizable. Further research with larger, more representative samples and longitudinal designs is recommended to build on these initial findings.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes: Jose Luis Huamani-Echaccaya

Reviewer #5: No

Reviewer #6: No

**********

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10.1371/journal.pone.0310244.r002
Author response to Decision Letter 0
Submission Version1
8 Jul 2024

Reviewer #1:

The article provides a compelling examination of alexithymia in preschool-aged children, an area that has been scarcely explored in the literature despite its significant implications for mental health. The study addresses a notable gap by investigating the relationship between child and parental alexithymia and its impact on early childhood psychopathology.

The research is well-written, presenting a clear methodology involving data from 174 parents of children aged 3 to 6. The use of validated questionnaires to assess alexithymia and psychopathology in both children and parents is a strong point, as it allows for a robust analysis of the relationships between these variables. The findings highlight the predictive power of parental alexithymia and emotion recognition abilities on child alexithymia, and how these factors relate to internalizing and externalizing symptomatology in children.

Notably, the study underscores the importance of alexithymia as a potential risk factor in early childhood, providing a foundation for future research aimed at understanding its causes, prevention, and intervention strategies for associated psychopathology. This perspective opens new avenues for exploring early intervention techniques and enhancing parental support programs to mitigate the development of mental health issues in children.

The article's limitations are punctually addressed, further strengthening its validity. The authors' thorough discussion of these limitations ensures that the conclusions drawn are well-supported and that the study provides a comprehensive overview of the topic.

Overall, this study is a valuable contribution to the field, offering fresh insights and setting the stage for future research on alexithymia and childhood psychopathology.

ANSWER:

Dear Reviewer 1,

Thank you for your thoughtful and encouraging review of our manuscript. We are delighted that you found our study to be a compelling examination of alexithymia in preschool-aged children and its significant implications for mental health. Your comments on the importance of alexithymia as a potential risk factor in early childhood and the need for future research on its causes, prevention, and intervention strategies are particularly encouraging.

Sincerely,

The authors

Reviewer #2:

the article titled Impact of alexithymia, speech problems and parental emotion recognition on

internalizing and externalizing problems in preschoolers is an innovative topic and difficult to conduct for preschoolers too. It will be the foundational stone for further related studies.

ANSWER:

Dear Reviewer 2,

Thank you for your positive feedback on our manuscript titled “Impact of Alexithymia, Speech Problems, and Parental Emotion Recognition on Internalizing and Externalizing Problems in Preschoolers." We are pleased that you found the topic innovative and recognized the challenges of conducting such research with preschoolers.

Your acknowledgment of our study as a foundational stone for future related studies is greatly appreciated. We hope our work will inspire and facilitate further research in this important area.

Sincerely,

The authors

Reviewer #3: The article presented by the authors aims to fill in the gaps on the topic of alexithymia, where research is scarce. The subject is complex, but the author has produced a very detailed and meticulous article. Previous articles have mainly looked at the adult or pre-school age, leaving out early childhood, which turns out to be extremely important and little studied, given the difficulty of the patient. In addition to congratulating the authors for having written an article on a very complex subject, providing data and considerations that are very important for the entire scientific community, I would like to make the following suggestions to improve an article that is already of a very high standard.

The objectives set by the authors have been respected and developed in an appropriate manner, providing an important starting point for future studies. First of all, the entire article should be reviewed in English, as there are redundant terms that can be improved by synonyms, if not grammatical errors that can be easily corrected.

ANSWER:

Dear Reviewer 3,

Thank you very much for the thorough and encouraging review of our manuscript titled “Impact of Alexithymia, Speech Problems, and Parental Emotion Recognition on Internalizing and Externalizing Problems in Preschoolers”, submitted for publication in PLOS ONE. We have thoroughly reviewed the manuscript to address grammatical errors and enhance readability by refining the use of synonyms where appropriate. We are very grateful for your helpful suggestions. Please find a detailed point-by-point response below. The respective changes in the manuscript are highlighted with track-changes to facilitate the follow-up. Page and line numbers refer to the track-changes document with changes visible.

Sincerely,

The authors

Introduction:

38-44: I would pay more attention to this paragraph, as it is of particular importance for the purpose of the article, I would improve its drafting, including any studies, regarding the identification of "pathology" when caregivers struggle to identify and interpret the child's emotions, identifying possible and viable solutions to remedy this problem.

ANSWER: Thank you very much for this important suggestion. Parent-reports on children’s psychopathology, especially in preschool children, are reported to be stable and reliable with few effects of confounding variables. Unfortunately, to our knowledge, there has only been a single study investigating the impact of parental alexithymia on parental report of children’s emotional skills. Thus, we have elaborated on the conducted study and emphasized its implications. As suggested, we have pointed out that assessing these variables is a possible solution to control for their impact (page 5, lines 94 – 105).

Study design:

The study design described in the introduction was explained in a clear and simple manner.

ANSWER:Thank you very much.

Materials and methods:

The flow of data collection, with the criteria used for the study, has been described in an appropriate and thorough manner, there are no corrections to be made as they are meticulous. The statistical data produced are meaningful, clear and easy to understand.

ANSWER:Thank you for your appreciation.

I would suggest an extension of the study court, for future implementation of the study, as it is often and scientifically important.

ANSWER:Thank you very much for pointing this out. The purpose of the present study was to gain a first glance at alexithymia in preschool age in a sample with sufficient power for the conducted analyses. Nevertheless, we fully agree that an extension of the sample size would benefit our conclusions and are planning a future follow up study with more objective measures of child alexithymia and a larger sample size.

The material presented for data collection, was well documented, described it impeccably, there are no corrections to be made.

ANSWER:Thank you very much.

Statistical analysis, well documented, highlighting the strengths and limitations of the study.

ANSWER:We are grateful for the positive feedback.

Conclusions:

The article is very long, but the importance of the topic justifies the length. All data, results and discussions are well documented. The article is of high scientific importance, a necessary result for the whole scientific community, with the aim of increasing knowledge in a topic that is still little explored. All data and methods used are user-friendly. The authors have presented an article that adheres to appropriate reporting guidelines and community standards for data availability. Applicable standards for study ethics and research integrity are met. The manuscript is well written and I believe it can be accepted for publication. Implementation with a series of case study articles is necessary for the future development of the topic of scientific interest, as I believe it will benefit the entire scientific community.

ANSWER:Thank you for your positive evaluation of our article. We appreciate your recognition of the importance and thoroughness of our work, and we are pleased that you find the manuscript suitable for publication. We will certainly consider your suggestion for future studies to further explore this important topic.

Reviewer #4:

ANSWER:

Dear Reviewer 4,

Thank you very much for the thorough and helpful review of our manuscript titled “Impact of Alexithymia, Speech Problems, and Parental Emotion Recognition on Internalizing and Externalizing Problems in Preschoolers”, submitted for publication in PLOS ONE. We have revised the manuscript to address your helpful suggestions. Please find a detailed point-by-point response below. The respective changes in the manuscript are highlighted with track-changes to facilitate the follow-up. Page and line numbers refer to the track-changes document with changes visible.

Sincerely,

The authors

1. In the abstract of the original article, the details of the materials and methods should be presented separately from the results. This ensures clarity and facilitates understanding of both the procedures employed and the findings obtained.

ANSWER:Thank you very much for this suggestion. We have gladly adjusted the abstract to include separate sections for methods and results (page 2, lines 26 – 32)

2. In Table 2 and 3: Maintain consistency in the notation and format of numerical data. The use of zero as an integer and then omitting it elsewhere could cause confusion. Uniformity in the presentation of results.

ANSWER:Thank you for this suggestion. In our tables we have followed the APA Style requirements which recommend removing leading zeros for values that cannot become larger than 0 (e.g., p-values). We have now adjusted the notation across tables, ensuring leading zeros are included throughout.

3. In the final paragraph of the discussion, spaced 9-10, it is noted that authors are cited in a format different from the Vancouver style. Unify the citation style with the rest of the content.

ANSWER:Thank you very much for spotting this. We have adjusted the citation format to ensure uniformity.

4. The conclusion focuses more on the relevance of the study and its implications for future research, rather than detailing specific findings that address the purpose of the study.

ANSWER:This is an important remark and we have adjusted the conclusion to include detailed findings and implications for future research as a follow-up (page 29, lines 536 – 550).

Reviewer #5: Interesting study from the point of view of the mental health of parents and children, however there are some observations that I detail below:

ANSWER:

Dear Reviewer 5,

Thank you very much for the thorough and helpful review of our manuscript titled “Impact of Alexithymia, Speech Problems, and Parental Emotion Recognition on Internalizing and Externalizing Problems in Preschoolers”, submitted for publication in PLOS ONE. We have revised the manuscript to address your helpful suggestions. Please find a detailed point-by-point response below. The respective changes in the manuscript are highlighted with track-changes to facilitate the follow-up. Page and line numbers refer to the track-changes document with changes visible.

Sincerely,

The authors

Summary: It is missing to place the study design and briefly the selection criteria. The wording of the statistics used is not understood.

ANSWER:Thank you very much for pointing this out. We have gladly incorporated information on the study design (online survey), the selection criteria (attending regular preschool) and included information on the statistical method used (multivariable linear regressions). Please see page 2, lines 26 – 34.

Introduction: Improve the wording by being more precise with what has been found in the review of the scientific evidence, improve the wording of the justification, and should conclude with the objective of the study.

ANSWER:We are grateful for the provided suggestions and have overworked the introduction to improve wording and formulations. We added additional sentences to point out the justification of the study (i.e., extensive research suggestion alexithymia as a risk factor but no research on alexithymia in preschool children; page 4, lines 77 – 84). The introduction now ends with explicit mention of the objective of the study and our hypotheses.

Material and method: Adequately describe the selection criteria, adequately detail the procedural phase, be more precise with the wording of the statistical analysis.

ANSWER:Thank you for this recommendation. We have extended our description of the selection criteria which were being the parent of children aged 3 to 5, the child attending a regular preschool, absence of intellectual disability, and adequate comprehension of the German language (page 7, lines 156 – 159). Additionally, we have elaborated on the procedural phase and recruitment (page 8, lines 171 – 175) and the statistical analysis (page 11, lines 242 – 256).

Results: Improve the wording of the interpretation of the results.

ANSWER:We have gladly implemented this recommendation and overworked the results, including more details and specifics in the descriptions (pages 12-16, lines 258 – 336).

Conclusion: Be more precise and objective in the wording.

ANSWER:Thank you for pointing this out. We have overworked the conclusion to involve more information on the objective results of the study with a brief outlook at possible implications and future research (page 29, lines 536 – 550).

Reviewer #6: The study presents an important and under-researched area in understanding alexithymia in early childhood and its implications for psychopathology, providing valuable insights into the potential intergenerational transmission of emotional processing difficulties. While the topic is relevant and the research question is well-framed, there are several methodological and interpretative concerns that need to be addressed to strengthen the manuscript.

ANSWER:

Dear Reviewer 6,

Thank you very much for the thorough and encouraging review of our manuscript titled “Impact of Alexithymia, Speech Problems, and Parental Emotion Recognition on Internalizing and Externalizing Problems in Preschoolers”, submitted for publication in PLOS ONE. We have revised the manuscript to address your helpful suggestions. Please find a detailed point-by-point response below. The respective changes in the manuscript are highlighted with track-changes to facilitate the follow-up. Page and line numbers refer to the track-changes document with changes visible.

Sincerely,

The authors

Major Comments:

Sample Size and Generalizability:

The sample size of 174 parents, including a subgroup of 27 children in an intervention program, raises concerns about the generalizability of the findings. More information on how these participants were selected and how representative they are of the broader population is necessary. Consider discussing the limitations of the sample size more explicitly and how it might impact the study's conclusions.

ANSWER:Thank you very much for pointing out this concern. Regarding the sample size itself we have conducted a power-analysis and determined that our sample size supersedes the 118 participants necessary to be able to draw meaningful statistical conclusions. However, our sample constitutes children in regular preschools in northeastern Bavaria, Germany, and generalizability to samples that do not attend preschool or with different cultural backgrounds may be difficult. We have added information on the selection of participants in the methods section and pointed out that all children attending regular preschools in northeastern Bavaria, Germany, were able to participate (page 8, lines 171 – 175) and included a discussion of the generalizability in the limitations (page 27, line 499 – 506). Additionally, we have added higher parental education as a point that may reduce generalizability in the limitations (page 28, lines 507 – 510).

Measurement Tools:

The reliance on parent-reported measures (Perth Alexithymia Questionnaire

Attachment Submitted filename: Response to Reviewers.docx

10.1371/journal.pone.0310244.r003
Decision Letter 1
Meng Runtang Academic Editor
© 2024 Runtang Meng
2024
Runtang Meng
https://creativecommons.org/licenses/by/4.0/ 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.
Submission Version1
28 Aug 2024

Impact of alexithymia, speech problems and parental emotion recognition on internalizing and externalizing problems in preschoolers

PONE-D-24-15302R1

Dear Dr. Jarvers,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Academic Editor

PLOS ONE

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #5: All comments have been addressed

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

Reviewer #5: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The revised methodology now provides a more comprehensive description of the study sample, including detailed inclusion and exclusion criteria. This addition strengthens the validity of the findings by ensuring that the sample is well-defined and appropriate for the research objectives. Furthermore, the procedures for measuring alexithymia, speech problems, and parental emotion recognition are now described with greater precision, including the specific tools and their psychometric properties. This thoroughness allows for better replication and understanding of the study design.

Overall, the changes inserted in the procedures and methods sections contribute to making this version of the article an even better one than the previous submission. The revisions provide greater transparency and rigor, which enhance the study's contribution to the existing literature on alexithymia, speech problems, and emotional development in preschoolers

Reviewer #2: the article titled Impact of alexithymia, speech problems and parental emotion recognition on

internalizing and externalizing problems in preschoolers is an innovative, complex and meticulous topic and difficult to conduct for preschoolers too. all the comments have been addressed but the statistics must be reviewed by an expert biostatistician.

Reviewer #3: The article presents a comprehensive and detailed account of the subject of atrial fibrillation, which is currently under-researched. Despite the complexity of the topic, the author has produced a highly detailed and meticulous article. The authors have met and developed their objectives in a way that sets an important starting point for future studies. Firstly, the article should be reviewed in English. This will remove redundant terms and improve the language where necessary. It will also resolve any grammatical errors.The study design was as follows:

The study design, described in the introduction, was explained in a clear and simple manner.

The materials and methods are clearly and accurately presented.

The data collection flow and the criteria used for the study were described in a suitable and thorough manner. There are no corrections to be made, as everything appears to be meticulous. The statistical data produced are significant, clear and easy to understand.

I propose extending the study court for future implementation of the study, as it is often and scientifically important.

The material presented for data collection was well documented, describing it impeccably. There are no corrections to be made.

In conclusion, it is clear that…

The article is comprehensive and deserves to be read in full, given the importance of the topic. All data, results and discussions are fully documented. This article is of great scientific importance and represents a significant contribution to the field of study. It addresses a topic that has been largely unexplored and is a valuable addition to the existing body of knowledge. The data and methods used are user-friendly. The authors have presented an article that adheres to appropriate reporting guidelines and community standards for data availability. They have also met the applicable standards for study ethics and research integrity. The manuscript is well written and should be accepted for publication. To further develop this topic of scientific interest, future work should include an implementation with a number of case study articles. This will benefit the entire scientific community.

Reviewer #5: It is an interesting topic that addresses a mental health issue related to parents and their children. It is well structured.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #5: No

**********

10.1371/journal.pone.0310244.r004
Acceptance letter
Meng Runtang Academic Editor
© 2024 Runtang Meng
2024
Runtang Meng
https://creativecommons.org/licenses/by/4.0/ 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.
2 Sep 2024

PONE-D-24-15302R1

PLOS ONE

Dear Dr. Jarvers,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

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If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

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PLOS ONE
==== Refs
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