Early Childhood Mental Health: The Continuum of Care
By Glenace Edwall
Glenace Edwall, Psy.D., Ph.D., LP, is Director of the Children’s Mental Health Division at the Minnesota Department of Human Services (DHS). She has a long-term interest in early childhood mental health development from both clinical and public policy perspectives. If you are interested in knowing more about what the DHS Children’s Mental Health Division is doing to build a care continuum for young children and their families, please feel free to contact Dr. Edwall at glenace.edwall@state.mn.us.
One of the most poignant moments I recall from clinical practice occurred as I talked with a father about the difficulties his preschool daughter was struggling with. He looked at me in disbelief and said, “It can’t be. She’s just too young to have mental health problems.” This parent’s response was very much a reflection of both professional and societal perceptions until very recently. As the extraordinary 2001 book From Neurons to Neighborhoods made clear, though, “Young children are capable of deep and lasting sadness, grief, and disorganization in response to trauma, loss, and early personal rejection. . . . Significant parent mental health problems, substance abuse, and family violence impose heavy developmental burdens on young children.” Young children, in other words, can experience both threats to their mental health development and actual mental health disorders. The remarkable news is, however, that these problems can be accurately and appropriately identified and that early interventions are effective in relieving immediate distress as well as preventing accumulating complications.
Early childhood mental health care can be defined many ways, but I favor one of the most inclusive definitions: it is a continuum of activities that support children’s mental health development. Early childhood mental health care provides both prevention and intervention. It includes children who will never have a mental health diagnosis, those who may develop a problem at some point, and those who have evident problems early on. It relies on a wide range of both professional helpers and “natural” helpers—those grandparents, child care workers, neighbors, church members or others who understand and are willing to support young children and their families. It embraces families as the most important people in their children’s mental health development, but it also acknowledges the importance of the quality of relationships that children begin to establish outside the family during their early years. To demonstrate the breadth of this definition, I’ll describe the range of activities that need to be part of a system of care for young children at four points on the continuum.
Activities that reduce risks and build protective factors for all children
All children deserve the same attention to their socioemotional (mental health) development as is given to their physical development. Socioemotional development is often described as synonymous with attachment because it is rooted in secure, caring relationships. A virtual mantra of early childhood mental health is a saying attributed to Urie Bronfenbrenner: Every child needs at least one adult who is utterly, irrationally in love with that child. A child’s caregivers both inside and outside the family may be easily able to do this based on their own strengths and experience. But many, ranging from uncertain first-time parents to those who are struggling with significant mental health difficulties, substance abuse issues, or other problems of their own, can benefit from additional resources.
One specific resource is a form of education and support referred to as anticipatory guidance—it occurs in many settings and can often be strengthened and extended to a wider range of families and caregivers. Whether provided by a pediatrician, public health nurse, Early Childhood Family Education (ECFE) facilitator, or a wise aunt, learning how a young child is developing can provide reassurance and direction for caregivers. Then, as caregivers learn how their child is developing a sense of self and how to relate to others, they can better anticipate their child’s needs and reduce unnecessary stress. They can also better help their child master developmental challenges and share with their child the joy and pride they feel as they see their child’s skills emerge. National health care surveys have demonstrated that far from experiencing this guidance as intrusive, most parents are eager to receive more of this form of support.
Identification of risks to development and early symptoms
Now that we realize that young children can have mental health challenges and disorders, there is greater acceptance of screening for early risks and symptoms. Screening for problems in the mental health development of young children is a brief process that determines, through the use of valid tools, which children are in need of more thorough evaluation. Lingering concerns about mental health screening can be allayed through clear definitions of what screening is—and what it is not. Screening does not establish a diagnosis and it does not serve as the basis for prescribing medications. For young children, screening must always be based on the voluntary participation of parents and the information they can provide about their child.
To ensure early identification of disorders and early, effective intervention, the 2003 New Freedom Presidential Commission Report on Mental Health called for routine mental health screening in a number of settings. Testimony to the New Freedom Commission by parent organizations supported this recommendation: parents reported that they often knew by the time their children were of preschool age that they needed help, but both health care and educational systems delayed providing them identification or services for several years. Since the early years are often critical years for the most effective interventions, children’s problems can easily become more severe and more entrenched if we wait.
Commonly used screening tools for young children, such as the Ages and Stages Questionnaire—Socioemotional (ASQ-SE), are completed by parents and can be used to offer reassurance about children’s development as well as establish the need for further evaluation for a small number of children. The ASQ-SE is one of several tools designed to be used at periodic intervals throughout the early childhood period, since new risks and symptoms may emerge with development. Good screening tools are marked by reliability and validity data, studies that demonstrate their applicability to diverse populations, and questions that allow parents to express their perceptions and concerns about their child’s development.
Developmentally and culturally appropriate diagnostic assessments
One of the most exciting clinical developments in early childhood mental health has been the development of diagnostic manuals specific to this age group. The best known of these is the Diagnostic Classification for Zero to Three (DC:0–3), a developmentally based system dating from 1994 that describes common difficulties faced by young children and their families. A growing number of states, including Minnesota, have incorporated “crosswalks” between the DC:0–3 and the more familiar DSM or ICD codes in their public mental health programs—this allows clinicians to provide developmentally appropriate diagnoses to even very young children. A somewhat different classification, the DSM-PR, has also recently been appended to the DSM-IV. These early childhood-specific systems also call attention to the role of cultural expectations in child rearing which shape young children’s experience, and to the importance of giving these full consideration in establishing a diagnosis.
As brief examples of what a difference it makes to have a developmentally appropriate diagnostic system available, consider some of the key aspects of DC:0–3. First, it includes categories that would not traditionally be considered part of “psychopathology” at all, but do occur in young children and create immediate problems and subsequent risks for them. These include regulatory disorders—shown, for example, by young children who persistently over- or under-react to touch, temperature, light, and other such stimuli—as well as sleep behavior disorders and eating behavior disorders. Similarly, the young child’s ability to relate and communicate is assessed, as is his or her reaction to trauma, grief, or loss. Second, a diagnosis cannot be made without considering the child in the context of the relationships that structure his or her life, so diagnoses must be thoroughly contextualized. As many clinicians have noted, DC:0–3 diagnoses are actually helpful in breaking down the stigma around mental health and mental health treatment because they clearly describe categories of concern that parents and other caregivers may have about young children. These are not arbitrary or pejorative labels, but instead are aspects of development for which more structured intervention may be needed.
Effective interventions for common early childhood mental health problems
The national movement to identify and implement evidence-based practices (EBPs) for common mental health disorders is progressing rapidly. While much of the early EBP effort was focused on adolescents with “deep end” service needs, programs and practices exist for young children as well. Many practices are already being employed in Minnesota, including replications of national programs such as Incredible Years and Parent-Child Interaction Therapy. At the Minnesota Department of Human Services, we are also working with the state of Hawaii to implement the approach they have developed that brings research findings into clinical treatment planning, including the early childhood period.
These early interventions are attracting considerable attention, as research demonstrates that they may have benefits far beyond satisfying the child’s or family’s most immediate concerns. Appropriate, successful mental health intervention can mean better readiness for learning in school, which in turn is a powerful prevention strategy for later social and behavioral problems. Prevention literature, in fact, is demonstrating that effective mental health treatment may do more to prevent delinquent behavior and school failure than more generic prevention strategies. Effective treatment reduces a potent risk factor in the young child’s life and also bolsters his or her resiliency for the challenges that lie ahead.
As these points suggest, early childhood is a period of rapid growth and development, when children’s paths are remarkably adaptable to change. As researchers and clinicians produce more usable guidance protocols, more efficient screening tools, more developmentally sensitive diagnostic procedures, and even more evidence-based intervention practices, we can expect to see many more children and families growing healthfully and successfully through these early years and beyond.
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