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Literature Review

Component 4: Helping children who are experiencing mental health difficulties

KidsMatter Early Childhood Component 4 Literature Review2

© Commonwealth of Australia 2012

Important Notice

KidsMatter Early Childhood Australian Mental Health Initiative and any other KidsMatter mental health initiatives are not to be confused with other businesses, programs or services which may also use the name ‘Kidsmatter’.

Content

www.kidsmatter.edu.au


sComponent 4: Helping children who are experiencing mental health difficulties 5

Background Information on KidsMatter Early Childhood.......................................................................5

Helping children who are experiencing mental health difficulties 7

Understanding children’s mental health and wellbeing..........................................................................7Mental health in early childhood...............................................................................................................7Mental health difficulties in early childhood...............................................................................................9Recognising difficulties in early childhood..............................................................................................10Do early mental health difficulties persist?..............................................................................................13An inclusive and accepting environment assists those experiencing mental health difficulties...............14

Responding to children who may be experiencing mental health difficulties....................................16Early intervention results in better outcomes for mental health..............................................................16ECEC services are in a unique position to support children’s mental health..........................................17How can ECEC services promote early intervention for mental health difficulties?................................18What can ECEC services do to address the needs of children who may be experiencing mental health difficulties?.............................................................................................................................................. 19Encouraging help seeking......................................................................................................................19Increasing collaboration between families, health professionals and ECECs.........................................21Developing partnerships with external agencies.....................................................................................22

Summary and Implications for Practice.................................................................................................23

References 24



Component 4: Helping children who are experiencing mental health difficulties

Background Information on KidsMatter Early ChildhoodKidsMatter Early Childhood is a national mental health promotion, prevention and early intervention initiative developed to support the mental health and wellbeing of young children in early childhood education and care services (ECEC). It has been developed in collaboration with beyondblue and Early Childhood Australia, with funding from the Australian Government Department of Health and Ageing and beyondblue. It involves families, early childhood professionals, and a range of community and health professionals working together to make a positive difference to young children’s mental health and wellbeing during this important developmental period of birth to five years.

KidsMatter Early Childhood uses a risk and protective factor framework to focus on four components that ECEC services can use to strengthen the protective factors and minimise risk factors for children’s mental health and wellbeing.

All four components are outlined below.

1. CREATING A SENSE OF COMMUNITY within ECEC services by focusing on belonging, inclusion, positive relationships and collaboration.

2. DEVELOPING CHILDREN’S SOCIAL AND EMOTIONAL SKILLS is fundamental to children’s mental health. These skills are developed through adults’ warm, responsive and trusting relationships with the children in their care, as well as through constructive peer relationships.



3. WORKING WITH PARENTS AND CARERS ECEC services and families can establish collaborative partnerships in the interests of their children. ECEC services can support families by helping them to connect with other families and by providing access to parenting support.

4. HELPING CHILDREN WHO ARE EXPERIENCING MENTAL HEALTH DIFFICULTIES. ECEC services are well placed to recognise when young children may be experiencing difficulties, to implement simple strategies to assist children, and to support families to seek additional help.

Definitions of terms used in this document

Children: Children from birth to five years unless otherwise stated.

Culturally and Linguistically Diverse (CALD): A broad concept that encompasses individual differences, such as language, dress, traditions, food, societal structures, art and religion.

Early childhood education and care (ECEC) services: Preschools, kindergartens and long day care services.

Early childhood staff: Educators, teachers, day care staff, integration aides, assistants, and other staff that are based within ECEC services.

Externalising: Disruptive, impulsive, angry or hyperactive behaviours (i.e. where the child ‘acts out’). These behaviours are generally readily observed and therefore are relatively easy to detect.

Internalising: Inhibited or over-controlled behaviours (i.e. where the child ‘holds in’ their difficulties), including withdrawal, worry, and emotional responses that primarily affect the individual child rather than having effects on others.

Mental health: Early childhood mental health involves being able to experience, manage and express emotions; form close, satisfying relationships; and explore and discover the environment.

Parents and carers: This includes biological mothers and fathers, parents of adopted children, GLBT parents, foster parents, grandparents, aunties and uncles. The primary caregivers of a child/children and are usually the child’s legal guardians.

Protective factors: Strengths that enable children to maintain positive mental health and wellbeing, even though risk factors for mental health problems are present.

Resilience: A person’s capacity to adapt to adverse situations in ways that enable them to cope positively and reduce or minimise negative impacts on mental health and wellbeing.

Risk factors: Factors that increase the likelihood that mental health difficulties will develop. The presence of particular risk factors does not necessarily mean a difficulty will develop. The presence of multiple risk factors usually increases the likelihood of difficulties developing.

Temperament: Individual characteristics and style of behaviour that a child is born with, now considered to have a basis in both biology and environment.



Helping children who are experiencing mental health difficultiesDURING THE EARLY CHILDHOOD PERIOD, FROM BIRTH TO FIVE YEARS, CHILDREN ARE NAVIGATING THROUGH SIGNIFICANT DEVELOPMENTAL MILESTONES AND ACQUIRING SKILLS WHICH FORM THE FOUNDATIONS FOR LIFELONG MENTAL HEALTH AND WELLBEING. During this period children are developing rapidly in a range of domains such as cognition, language, physical, social and emotional development. This early development can be significantly affected by social, emotional, attention and self regulation impairments with the potential to disrupt the usual pattern of developing brain architecture resulting in long term consequences for learning and mental health.1,2 Early recognition and intervention for children showing signs of mental health difficulties during this critical period can help to prevent difficulties becoming worse and/or interfering with children’s developmental progress, as well as address already present stress and distress. Awareness of mental health difficulties is particularly important for those who work in services, such as ECEC services, where they are likely to observe children who may be experiencing mental health difficulties. 3

Component 4 of the KidsMatter Early Childhood initiative: Helping children who are experiencing mental health difficulties focuses on understanding children’s mental health and wellbeing and responding to children who may be experiencing mental health difficulties. Each of the target areas is discussed in detail below. The numbers appearing in the text are linked to references listed at the end of the document. If you would like more information about the ideas presented in this paper, the reference list is a starting point.



Understanding children’s mental health and wellbeing Mental health in early childhoodResearchers highlight that early childhood mental health needs to be understood within context of key relationships which play a critical role in shaping children’s social, emotional and cognitive development 2,4,5and has been defined as:

A young child’s capacity to “experience, regulate, and express emotions; form close and secure interpersonal relationships; and explore the environment and learn- all in the context of family, community, and cultural expectations for young children. Infant mental health is synonymous with healthy social and emotional development.”6

As well as having a biological basis, children’s mental health is generally considered to be influenced by the contexts in which they live, and the interrelationships between these settings, e.g. family, ECEC service or school, and the broader community.7

One way to understand mental health in early childhood is through a risk and protective factors framework. Children who are exposed to multiple risk factors during early development are most likely to show evidence of difficulty later on in life.8 There are a range of different risk factors that can affect children’s mental health, including family history, genetic and environmental factors. Some children are born with significant genetic risk factors for some disorders, for example, Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD).9,10 However, the cause of these disorders is quite complex, in that environmental factors have also been suggested to play a role in their development.10,11 Similarly, there has been some evidence to suggest that the manifestation of mental health difficulties such as anxiety and depression may also be related to a combination of biological, environmental and social influences.12

Environmental risk factors include financial difficulties, family history of mental illness, maternal depression, and stressful life events such as parental separation or family violence, poor parenting quality of early childrearing,13 and family dysfunction.12,14-20 Experiences of significant trauma such as child maltreatment have also been associated with an increased risk for mood and anxiety disorders in later life.21,22

In contrast, the presence of protective factors decreases the likelihood of mental health difficulties in early childhood, even when children are exposed to risk factors. Protective factors that support children’s mental health include parental care and affection, secure attachment, experiencing positive relationships, assisting children to experience, express and manage their emotions and providing a warm and secure environment.14,23-27 Positive social interactions with their peers appear to protect children from developing internalising



disorders such as depression, with the quality of these interactions found to be particularly important for girls.15,28

Research has also identified that a stable home environment has been identified as a protective factor for children’s mental health.19 Also, children of parents who have an authoritative (as distinct from authoritarian) parenting style (e.g., parents displaying high warmth, involvement, clear communication of expectations and reasoning) showed less internalising problems and were less likely to show behavioural difficulties.29 The number of social opportunities available to children attending child care has also been related to reduced internalising behaviours in young children.16

One study found that children with stronger resources (i.e., positive family climate and parental support) who experienced moderately adverse life events displayed difficulties (as measured by the Strengths and Difficulties Questionnaire (SDQ)) similar to children without risk exposure. From this research it is clear that when children are exposed to a stressful environment, strong resources can have a significant impact on protecting them from mental health difficulties. For children who have not had the experience of adverse events, positive relationships build a buffering system to prevent poor mental health.30

Mental health difficulties in early childhoodThe term ‘mental health difficulties’ covers a broad range of emotional and behavioural difficulties that cause concern or distress, and frequently affect children’s learning as well as their behaviour in different settings.31

The rapid development occurring in the early years means that children’s behaviour needs to be viewed within a developmental framework meaning that the behaviours that would be concerning in later childhood are more commonly seen in infants. For example, being distressed when a primary caregiver is out of sight is expected for a 10 month old baby, but becomes more problematic for a 4 year old. A major challenge is that children in this age group grow and develop at different rates and stages, making it difficult to recognise when a concern may be present.31

However, research has shown that infants and young children can and do experience the same mental health conditions as adults. The way these disorders are expressed are somewhat different during the early childhood years and can be more difficult to identify.32,33


Prevention and early intervention programs that target the family, school and community have the capacity to decrease the prevalence and the degree of mental health difficulties experienced by young children.


Some of the behaviours that young children display that can be a sign that they may be experiencing mental health difficulties include;

persistent sleep and feeding problems; irritability and fussiness; uncontrollable crying that is not responsive to soothing; difficulty adjusting to new situations; inability to form relationships with peers and adults; excessive violence towards other children; significant and age inappropriate separation anxiety very withdrawn behaviour.34

According to a review published by the Australian Institute of Health and Welfare,35 an average of 20 per cent of children and adolescents living in Australia experience mental health issues, and nine per cent of children experience persisting emotional and behavioural problems. It has also been shown that up to 23.5 per cent of Australian children are developmentally vulnerable on one or more domains of the Australian Early Developmental Index, including; physical health and wellbeing, social competence, emotional maturity, language and cognition prior to school entry.36 Only one quarter of children experiencing mental health difficulties receive professional support, and only half of those who have severe problems have access to mental health care.37 Internationally, it has been reported that the prevalence of clinically diagnosed childhood psychiatric disorders is within a range of 12 to 20 per cent. 38-40 Studies have also reported that there has been an increasing prevalence of early childhood psychiatric disorders with onset occurring at younger ages. 14,41-43 It is now well understood that many psychological disorders that begin in the childhood years persist into adulthood. 44

Early childhood is an especially sensitive period for the developing brain.45 During the first three years of life a remarkable period of development occurs, where exposure to positive experiences can help develop the brain networks required for a range of skills.1 At the same time, this period is also characterised by great vulnerability, as negative experiences can also influence the brain’s connections and networks, potentially leading to mental health difficulties.46 Children in their early years are considered most at risk when faced with negative experiences as their physical and psychological resources to cope with stress are limited.2,47 Responsive care giving from parents and carers develops the necessary brain connections that help children build the skills to adapt to the challenges of the environment.48 The neuroplasticity of the brain (i.e., the brain’s ability to change functionally and structurally as a result of environmental input) can be positively influenced by early intervention and treatment that can help children achieve the best outcomes for their mental health and wellbeing.45,49

It is now well understood that infants are born with the cognitive capacity to manipulate their environment and actively participate in social exchanges to meet their needs. Research has suggested that this level of competence allows infants and children to



successfully engage in early intervention and treatment that supports their development and reduces the likelihood of early difficulties becoming more problematic.2,50-52

Recognising difficulties in early childhoodResearch into the identification of mental health difficulties in early childhood has increased in recent years.

Early childhood mental health difficulties have been organised in the following categories; externalising and internalising disorders (i.e., hyperactivity and anxiety); relationship disorders (e.g., disorganised attachment and autism spectrum

disorders); regulatory disorders (i.e., disordered sleep and eating patterns).49,53

The persistency and frequency of particular behaviours are significant factors in recognising children who may be experiencing mental health difficulties. For example, most young children encounter challenges with their ability to self-regulate, however research has shown that infants with significant regulatory problems (i.e., sleep disturbances, poor self-soothing, distress associated with routine, sensory experiences such as touch) are more likely to be diagnosed with developmental disabilities at three years of age.54 In particular, infants that experienced feeding difficulties along with other regulatory problems were more likely to be diagnosed with a pervasive developmental disorder.55

Infants, toddlers and preschoolers are in a period of rapid development where there is great variability in expressions of behaviour. Because of this, the distinction between what is and what is not a disorder can be very difficult.56 In a large study of preschool aged children; the most common mental health difficulties diagnosed were oppositional defiant disorder, parent-child relationship problems, ADHD, depression, and separation anxiety disorder.57

The symptoms of ADHD are commonly observed in preschool aged children; however a diagnosis is not typically made until later in childhood56 Hyperactivity, impulsivity and inattention are characteristic symptoms of ADHD and can be presented alone or in combination. Recent studies reported that 40 per cent of healthy preschoolers displayed hyperactive behaviours, however inattentive symptoms were far less prevalent and may possibly differentiate preschoolers with probable ADHD from typically developing children.56 Common early childhood behaviours such as disobedience and aggression raise concerns as to whether it is possible to accurately diagnose preschoolers with


A significant factor in recognising children who may be experiencing mental health difficulties is the persistence and frequency of particular behaviours.


behavioural difficulties such as Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD).58

Anxiety is another common disorder diagnosed in childhood.58 Anxiety problems can have debilitating social, emotional, and academic consequences for children and their families. In childhood, anxiety sensitivity (or heightened fears) is a significant risk factor for the development of anxiety disorders in adolescence and adulthood.59 An Australian study reported that in their sample, 4 to 14 per cent of children aged 1.5 to 3 years had a clinical level of internalising difficulties.60

The development of childhood anxiety disorders can involve complex interactions between psychological, biological and environmental factors. Risk factors include anxious-resistant attachment, parental anxiety, a child’s temperament style of behavioural inhibition, stressful life events and parenting style characteristics.60 Results from a recent study also suggest that the quality of the infant–caregiver attachment plays a role in the development of childhood anxiety.61,62

It has been found that the most prevalent anxiety symptoms in three to five year old children relate to fears about physical injury (e.g., the dark, spiders, swimming), social fears (e.g., playing with other children, meeting unfamiliar people), and separation anxiety (e.g., sleeping by themselves or being away from home).62 Three year olds were particularly distressed by being left at preschool or with a babysitter, whereas the older preschoolers were more likely to be anxious about talking in front of the class or their preschool group or behaving inappropriately in front of others.62 These age differences are consistent with children’s developing awareness of social performance and self-consciousness.62

The idea that infants and preschoolers suffer from depression has been subject to much controversy and was rejected by some researchers and clinicians for many years.16,63 More recently, it has been found that depression in early childhood does exist, and can be distinguished from other child psychopathologies.63 It has been

suggested that preschool children with major depressive disorder are more likely to demonstrate negative emotional states, for example, sadness, irritability, somatic complaints and feelings of guilt that are resistant to change.64 Similarly, other research has found that guilt and excessive fatigue were highly specific to the diagnosis of preschool depression, and may present with other more commonly recognised symptoms such as sleep problems, weight changes, lack of enjoyment during pleasurable activities, psychomotor agitation and reduced cognitive performance.65,66


Preschool children with major depressive disorder are more likely to demonstrate sadness, irritability, somatic complaints and guilt than older children.


There is a growing body of evidence to suggest that Autism Spectrum Disorders (ASDs) can be identified before 12 months of age67,68 however many children go undiagnosed until after the age of three or even later.69-71 The core features of ASDs include deficiencies in joint social interaction, limited verbal and non-verbal communication and restricted repetitive behaviours and interests.33

Similar signs were shown in children aged 12 months, with additional difficulties including difficulties in alternating gaze between objects and other people, limited use of pointing to objects or other people and less frequent instances of showing an object to another person.68 These signs may also be reflective of other disorders, such as global developmental delay and language disorder.55

Young children are especially vulnerable to the effects of trauma as they are highly dependent on adults for protection and have limited ability to control events occurring in their immediate environment.47,72 Trauma can be experienced due to a number of reasons, such as being involved in a motor vehicle accident, child abuse or neglect, sudden loss or death of a significant person, significant medical procedures, war, removal from family, family breakdown and cultural dislocation. Visualisations or re-experiencing memories of the trauma, repetitive behaviours, such as acting out the trauma over and over in play, dissociative symptoms (i.e. acting stunned or numb)73, specific fears associated with the traumatic event, such as hiding under the table when hearing loud noises and altered views about certain people and the future are considered to be some of the typical behaviours presented by traumatised children.74

Children under six are likely to report very detailed accounts of their traumatic experiences with their drawings and play commonly reflecting what occurred at the time of the trauma.72 Hyperactivity, aggression and antisocial behaviour were also common reactions seen in traumatised children and are often misdiagnosed as symptoms of ADHD.75 Traumatised children may regress, function at a level lower than expected for their age group, develop new fears and become hypervigilant, show signs of reckless behaviour, become anxious around separation from caregivers and similar to depressive disorders frequently report psychosomatic aches and pains.76,77

Do early mental health difficulties persist?Many psychological disorders previously thought to appear in adulthood have now been found to originate much earlier, sometimes in childhood and adolescence.42,78 Without early intervention, mental health difficulties evident in early childhood can become significant mental health problems in later life.2 Some researchers believe that children with behavioural difficulties in preschool ‘outgrow’ them during the course of their development.79 However reports from the Australian Temperament Project found that 50 to 60 per cent of children aged 11 to 12 years exhibited both internalising and externalising problems and that they showed signs of these behaviours from when they were three to



four years of age.80 So while some children may ‘grow out of it’, around half of them will not, unless early identification is followed by early and effective intervention.

Studies have found that up to 50 per cent of children below the age of two years who have significant social and emotional difficulties show ongoing difficulties.81 One third of children were identified as having social, emotional and behavioural difficulties at 12 to 36 months of age, and of these

children half continued to demonstrate clinical level problems at primary school age.82

Longitudinal studies have found that children presenting with externalising or internalising behaviours at age three were more likely than children that did not present with these behaviours to show evidence of mental health difficulties in late adolescence.83,84 A similar study conducted in Australia found that behavioural and language difficulties in early childhood related to a higher risk of antisocial behaviour in adolescence.85 An association has also been found between babies’ irregular sleeping patterns and externalising behaviour and difficulties soothing at ages three and six years.86 Furthermore, a large proportion of children deemed ‘hard-to-manage’ in preschool were more likely to show clinical level externalising problems at primary school age.86,87

There has been a lot of research to suggest that children with mental health difficulties are at risk of poorer outcomes in a range of areas.88,89 Diagnosis of depression during childhood has been associated with increased risk of depression relapse in adulthood, co-morbidity with other psychiatric conditions, increased suicidality, poor psychosocial functioning and cognitive deficits.90,91 A longitudinal study of the long term outcomes of childhood mental health problems found that children with conduct disorder, internalising symptoms and attention-type problems were more likely to be diagnosed with other psychiatric conditions and/or engaged in criminality and antisocial behaviour in adulthood.92,93

Another study94 indicated that emotional and behavioural difficulties during the preschool years create a developmental pathway that leads to internalising and externalising problems into the adolescent years. Depressive symptoms have been shown to follow a similar pattern where over half of a sample of children and adolescents diagnosed with depression showed ongoing depressive symptoms into early adulthood.95


Without early intervention, mental health difficulties evident in early childhood can become significant mental health problems later in life


An inclusive and accepting environment assists those experiencing mental health difficulties Stigma is a perception which identifies people as different due to a characteristic considered to be undesirable by the general community.96 Stigmatised individuals often experience discrimination, prejudice and ignorance due to these characteristics.96,97

The stigma related to mental illness has often resulted in it being hidden within the community.4 Even today, with greater public awareness and acceptance of mental health related concerns, the stigma of having a mental illness remains significant. 98,99 Individuals who live with mental illness are more likely to follow through with treatment at services which are perceived to be less stigmatizing.100 It is for this reason that professionals working in this area have a sensitive attitude toward the effects of stigma and aim to reduce negative attitudes towards individuals accessing support.96,101,102

Stigma does not only affect the individual with the mental illness themselves, but also those around them. The general community tends to overly attribute a child’s mental health difficulties to poor parenting skills, leading to family stigma.103 By addressing public misinformed beliefs, scepticism and lack of knowledge surrounding mental health, families may be more likely to seek help if they are not afraid of being stigmatised and blamed for their children’s mental health difficulties.104

Early childhood staff, like mental health professionals, can play a vital role by helping families view mental health services as non-stigmatising and helpful in addressing mental health needs. They can help families to understand that mental health difficulties as being part of many children’s experience, which can reduce some of the fear and concern experienced when difficulties arise.104 A joint understanding of mental health difficulties between early childhood staff, mental health professionals and families paired with greater public awareness and education can help reduce stigma and negative attitudes. 109,110

Early childhood staff can assist develop parent’s mental health knowledge and their use of mental health services. Recent Australian research found that there was poor mental health literacy in the general community.105 In order to improve public understanding of mental health issues and difficulties dissemination of information is critical.105,106 Such information could include risk and protective factors for mental illnesses, signs and symptoms of different mental illnesses (or specific disorders), their causes, interventions (including self help and professional support) and how to seek more information and support.105,107,108


Stigma is a perception which identifies people as different due to a characteristic considered to be undesirable by the general community.


There are many factors that may deter families from seeking help. These include families being unsure about where to get help or their service perception or past service history has been unfavourable.109-112 Parents have expressed concerns about there being a lack of services for their child, little information about services, long waiting lists and having to continuously repeat their child’s story to different professionals. Parents can be exhausted and confused from managing the system of services as well as trying to understand their child’s problem.102,113,114 Often, professional help is only sought by parents when they feel they can no longer manage their child’s difficulties on their own and see the need for professional intervention.115 Further factors in children not receiving help include the parent’s disagreement with the intervention offered e.g., medication rather than therapy;116 or when families and ECEC services have negative experiences or expectations of treatment.110,111

Developing supportive community environments and delivering appropriate mental health messages can help to improve mental health literacy.105,117 People who are aware of, and have knowledge about, mental health problems are more likely to recognise signs and seek support.105 In this sense, early childhood staff can play an important role by increasing parents’ mental health knowledge and their use of mental health services. For example, providing information about when to seek help, what to expect from a service and what information could be shared with a professional could help those who are reluctant to seek out help.118 Additionally, educating parents about the importance of the child’s first years in developing healthy social and emotional development can assist in addressing children’s mental health needs.113

Research has found that child care workers tend to underestimate the seriousness of mental illness.102 A limited knowledge about mental health and inadequate preparation to deal with childhood mental health difficulties has also been reported by staff.119-121 As a result many early childhood staff have strongly supported the idea of having further training in this area.121

Training and continuing professional development for professionals who work with both at risk and low risk children and their families is very important, especially in developing a non-judgmental attitude towards these families.122


Professional development and reflective practice for early childhood staff is important in developing a non-judgemental attitude towards mental illness


Responding to children who may be experiencing mental health difficultiesEarly intervention results in better outcomes for mental healthEarly intervention strategies aim to effectively address difficulties in children at a young age, to reduce the risk of future problems developing and promote the necessary conditions for healthy child development 110,119,123-125 Early treatment for mental health difficulties during early childhood can include working directly with and infant or child and their family, as well as promoting a positive environment, promoting sound parenting behaviours and promoting social and emotional learning.119

Early childhood mental health promotion is one way of mental health difficulties across the population. It is underpinned by the significance of early infant-caregiver relationships, and is generally the main focus of intervention in this age group.33,126,127

The quality of early attachment relationships significantly influences the developing brain.128 Interventions that promote attachment experiences have been shown to support the development of positive relationships essential for mental health over the lifespan.1,129 There are a range of interventions available to support attachment and improve supportive, emotionally responsive parenting. One attachment based intervention, Circle of Security, focuses on changing relational patterns between caregivers and children. Infants showed the best therapeutic outcomes when their parents were able to recognise their difficulties. Through participating in a Circle of Security program, caregivers become more sensitive to children’s needs and more able to provide support when their children show signs of emotional distress, therefore facilitating more secure patterns of attachment. 130

Another intervention informed by the theory of attachment, ‘nurture groups’, was developed to assist preschool and school aged children with social, emotional and behavioural difficulties within the classroom setting.131 The emphasis of the intervention was to help small groups of children develop close relationships with their teachers, to enhance their social and emotional skills and thus reduce their behavioural difficulties. Following the study, significant improvements were found in children’s social and emotional skills which resulted in reduced challenging behaviours.131 Additionally, the younger the children were when they participated in the nurture groups the greater the improvements were in their social and emotional skills.132

The Australian intervention program Tuning in to KidsTM has been developed to improve supportive and emotionally responsive parenting.133 Tuning in to KidsTM has been used with parents during their children’s preschool years and shown to improve children’s


The quality of early attachment relationships significantly influences the developing brain.


emotional development and behaviour.133 The theory behind this intervention, proven through evaluation research, is that children develop the ability to think about emotional experiences and regulate their responses when parents attend to low or moderate intensity emotions and support, soothe and help them learn about these emotions.133

Treatment and interventions for children with internalising problems have also shown positive results, and these are maintained over a long period of time.134,135 Play therapy techniques have been effective for preschoolers with significant internalising symptoms where symptoms have been reduced as reported by parents on a range of measures.136,137 Parental involvement in the interventions played a significant positive part in the overall result of the children’s outcomes.138,139

Early intervention programs that target the child and his or her environment, including family, ECEC service, and community have been shown to decrease the prevalence and the degree of mental health difficulties experienced by young children140 and improve life-long outcomes.141

ECEC services are in a unique position to support children’s mental health An Australian study of socioeconomically diverse families reported that 39 per cent of infants presenting for routine maternal child and health visits were identified as at risk for developing mental health difficulties.142 A

large proportion of these infants are likely to attend some form of early childhood service as they get older, when signs of early problems may be apparent.

A substantial proportion of children aged 5 and under in Australia attend a Government approved childcare service (33.9% in 2009) and nearly 70% of four to five year olds attend preschool. 143 This high level of engagement with early childhood services means early childhood staff are very well placed to recognise children who may be experiencing mental health difficulties. It has been suggested that the most successful early intervention strategies have been built on a foundation of successful parent-staff relationships.144 Early childhood staff also have opportunities to engage with parents or carers of the children they see on a regular basis, providing further avenues to assist those children who may be presenting with mental health concerns Further information about developing partnerships can be found in the KidsMatter Early Childhood Component 3: Working with parents and carers literature review.

A proportion of preschool children with social and emotional issues go on to develop more significant problems through childhood and adolescence.78,145 Therefore it is important that early childhood staff can recognise possible difficulties and facilitate links to support, including a thorough assessment by trained health professionals if appropriate. The use of


The most successful early intervention strategies have been built on a foundation of successful parent-staff relationships.

Working together with children, families, mental health agencies and


multiple informants, i.e., parents, early childhood staff, teachers, paediatricians and psychologists are the key to ensuring that children are assessed appropriately and provided with the supports they need when necessary.146

How can ECEC services promote early intervention for mental health difficulties?There is strong support for mental health promotion in childhood. Research shows that only a small number of children with mental health difficulties are likely to be referred on for further assessment and treatment.24,37 Therefore there is a need for more formal processes to be put in place in ECEC services to address the mental health needs of children.119,147 Research has identified that some early childhood staff report challenges in recognising children that display potential mental health difficulties, many times from the fear of labelling the child or making parents feel responsible for their child’s difficulties.148 Within the early childhood service, formal procedures and policies to help observe and address the signs of early mental health difficulties in childhood can be extremely beneficial for both the staff working with children and the families who attend.47

When staff can develop positive relationships with parents and carers, have time to consider the physical and emotional quality of the environment, recognise the professional and personal expertise they can share and have the knowledge to ask for support when needed, they are well placed to promote children’s mental health.149 Working together with children, families, mental health agencies and organisations helps facilitate early mental health intervention and treatment.150 These partnerships work best when each partner collaborates to support children’s mental health.151

Strong relationships between mental health professionals and early childhood staff can provide staff with the appropriate tools to meet the needs of families attending their service. Furthermore, these relationships allow early childhood staff to be a valuable part of the intervention, especially in supporting families to utilise the support of an external service.47

What can ECEC services do to address the needs of children who may be experiencing mental health difficulties?ECEC services are well placed to recognise early social and emotional difficulties as well as signs of developmental challenges in children attending their services.152 Recognising difficulties does not involve making a mental health diagnosis, but rather is an opportunity for families and staff to understand a child’s experience, identify whether a shared concern is present and consider if further assessment is required.34 ECEC services that have adequate knowledge about help seeking behaviour can ensure that children at risk of developing mental health difficulties are recognised early.84,153

Following observation, and a discussion with families, early childhood staff can establish specific concerns about a child’s mental


Working together with children, families, mental health agencies and

The trust and respect developed through the partnership between families and staff also plays an important role when seeking external assistance.


health and provide families with the necessary information in order to obtain follow up assessment and support.152

It is well documented that with appropriate training staff feel better equipped to: speak confidently about mental health and professional help seeking with families; recognise children experiencing challenges; provide opportunities for early intervention.151,153

Providing best practice training for service providers has been found to enhance service delivery and helps services focus on increasing awareness of mental health difficulties.154

The likelihood of referrals being followed through increases when early childhood services have developed strategies for identifying mental health concerns and have an awareness of local support agencies.154 The trust and respect that has developed through the partnership between families and staff also plays an important role when seeking external assistance.154

Encouraging help seeking Help seeking behaviour is described as communicating a problem to obtain support, advice or help.155 Young children rely on parents and carers to identify their problems and carry out the help seeking process when experiencing difficulties.156,115,157 It has been found that families often approach GPs in the first instance to discuss their child’s difficulty and establish how to navigate the service system.116

The decision to seek mental health assistance can be affected by multiple issues including the child’s level of distress, being referred by others, having knowledge or previous experience with services, perceptions of getting help, being mandated to do so (e.g., by child protection agencies) and the support of others.116,158,159 The process of seeking help is also influenced by various factors including social support, both formal (e.g., paediatrician, early childhood staff, psychologist) and informal (e.g., sister, friend, neighbour) and accessibility (e.g., rural versus metropolitan locations).116 The role of social support has a significant impact on help seeking and assisting families living with mental illness. This is especially true when mental health support services are not always readily accessible within communities.115,160 Encouraging the development of support networks and other factors that affect the decision to seek help can assist families and services in confidently responding to children’s mental health difficulties.


Social support has a significant impact on help seeking and assisting families living with mental illness.


Barriers to seeking help can continue to be a challenge for families and early childhood services. There are different options available that can help families and services overcome these difficulties.

Parents and carers are ‘gateway providers’ for children’s access to services. As ‘gateway providers’ parents and carers help-seeking behaviours can influence whether a child obtains help or not. The variables and possible barriers that may affect their help-seeking behaviour include:

level of parental concern; beliefs about the causes of their child’s problem; ability to deal with the problem; possible threat to parental self-esteem and parenting; perceived burden of the problem; fear or mistrust of services; feelings of discomfort when disclosing emotions; concerns with privacy and confidentiality; perceptions of costs outweighing the benefits of assistance; parental knowledge and attitudes towards services; perceived need for services.110,111,115,116,157-159,161,162

Educating the community about mental health issues can help overcome many barriers to help seeking. An important factor related to parents seeking help is recognising that their child actually has a difficulty.116,163,164 Strong predictors of problem recognition by parents include the child’s age, severity of the problem, level of impairment and presence of externalising behaviours in the child.109,161 Research has found that parent’s gender, location, language and culture can play a part in seeking help.115,118 In some cultures, parents are more likely to persevere with their child’s problem than rely on professional help.109

Other obstacles include parents’ readiness for change, believing that the problem will improve on its own over time and feeling competent to handle their child’s problems on their own without any intervention.110,163,165

Useful strategies to address such fears include: providing information about what to expect from mental health services before they are

accessed; providing information about what mental health professionals do; highlighting the benefits of emotional awareness.

Many parenting programs use ‘classes’ to help reduce the stigma attached to counseling or psychotherapy.111 Research suggests another way to assist individuals with their help seeking behaviours is to receive supportive feedback from other service users or from



leaders in the community.110 A ‘help seeking policy’ (via a website or bulletin board) can be a good way to communicate the importance and value of seeking help.159

Increasing collaboration between families, health professionals and ECECsResearch has found that ECEC and health professionals who engage in collaborative partnerships with parents and carers help families feel more confident in receiving support. In some cases, where ECEC and health professionals appear to be working effectively with a child on their own, families may feel that they are not engaging in a shared role and subsequently withdraw from the early childhood service.122 A family centred service is more likely to facilitate families accessing services as their child gets older if they have experienced respectful and genuine relationships and partnerships during their child’s early years.122,144

Improving communication and shared understanding between professionals and families has been cited as a benefit to successful help-seeking and working effectively with external agencies. Australian research has found that a collaborative approach between health professionals and ECEC services helps build staff morale and enhance their feelings of effectiveness, along with their self confidence, motivation and enjoyment. Another outcome of collaboration within an early childhood service is reduced frustration and feeling better able to support children. Having contact with health professionals helps ECEC services become more aware and informed of other agencies that can support families and their children. An approach of support and understanding between services has been shown to effectively increase collaboration between families, health professionals and ECEC services.166-168 Collaboration can assist in promoting service usage and the development of partnerships.

Suggestions for how ECEC and health services can work together to assist families access support and promote collaboration includes:

providing low-cost programs; having varied appointment times and locations; providing child care at services; assisting with transportation; accommodating for cultural, language and literacy differences; hosting events with professional services, providing easier access to these services

for families.110

Developing partnerships with external agenciesOnly one quarter of children experiencing mental health difficulties receive professional support, and only half of those who have severe problems have access to mental health care.37 More than half of children who have received mental health support have been referred through the education sector, indicating that this is an


A ‘help seeking policy’ can be a good way to communicate the importance and value of seeking help.


important entry point for family access to mental health services.169 ECEC services can begin building relationships with mental health and community services to further extend the support they can provide to children and their families.153,170

Families are reliant on those they turn to for advice to have a good understanding of the local mental health, community and government supports available to them. Through creating partnerships between local services, the complexity of the service system is reduced thus enabling families to access support more readily. This can help to ensure ongoing care by avoiding inconsistencies, misinformation or gaps between services.151 The sharing of knowledge, resources and strategies between services working with families are crucial to overall success of an intervention.152,171

Developing partnerships and strong collaborative relationships between ECEC and mental health services both inside and outside the local community provides families with a range of services they can access, and can be a source of training opportunities for early childhood staff.34 Health professionals gain an understanding of the context in which children live and learn, and the significant people with whom they regularly interact, through the relationships they build with families and ECEC services. 47

Consultation between ECEC services and mental health professionals has positive benefits for the services who work with children that have emotional and behavioural difficulties.172 Mental health consultation, focused on positive child-adult relationships and effective behavioural management strategies for preschool teachers and families, has been successful in reducing disruptive behaviours in children.173 Families can benefit from attending a service that has an awareness of mental health difficulties and the various risk and protective factors that influence children’s mental health and wellbeing.172 It can be of great value to a service and to families to share knowledge and understanding with mental health consultants. The successful partnership with families, ECEC services and mental health consultants can positively affect the development of children’s mental health and wellbeing.

Summary and Implications for Practice Having a clear understanding of the mental health services available to children and families helps early childhood staff identify the children in their care who need extra support and where to access that support. Early childhood staff who have processes within their services to recognise children showing signs of mental health difficulties, should also have well developed referral pathways for families requiring extra support.151 These pathways need to be inclusive, in that early childhood staff, parents, children and mental health professionals collaborate, providing coordinated interventions to meet the best interests of the child and their family.174174



The KidsMatter Early Childhood initiative promotes positive relationships between parents, carers and early childhood staff to gain a further understanding of children’s mental health and wellbeing. Throughout this review the different elements of children’s mental health and wellbeing have been discussed and the importance of understanding and responding to mental health difficulties has been a main focus. The influence of environmental factors, attitudes towards mental health, help-seeking behaviour, early intervention and collaborative partnerships between families, early childhood services and health professionals have been identified as key areas to help work towards prevention of mental health difficulties in early childhood.

It is clear that mental health difficulties occur in young children, and for many children these problems persist throughout primary school age, adolescence and early adulthood. ECEC staff working with families to increase protective factors and understand mental health difficulties, along with developing skills in responding to children experiencing mental health difficulties will help ensure that young children are provided with the best level of support and understanding during the early stages of development.



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