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08 Fall
Literature Review
Component 4: Helping children who are
experiencing mental health difficulties
KidsMatter Early Childhood Component 4 Literature Review 2
www.kidsmatter.edu.au
© Commonwealth of Australia 2012 Acknowledgement
KidsMatter Early Childhood Mental Health Initiative has been
developed in collaboration with beyondblue, the Australian
Psychological Society, Early Childhood Australia and, with
funding from, The Australian Government Department of
Health and Ageing and beyondblue.
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’.
Disclaimer
While every care has been taken in preparing this publication,
Beyond Blue Ltd, The Australian Psychological Society Ltd
and Early Childhood Australia Inc and the Commonwealth of
Australia, do not, to the extent permitted by law, accept any
liability for any injury, loss or damage suffered by any person
arising from the use of, or reliance on, the content of this
publication.
KidsMatter Early Childhood Component 4 Literature Review 3
www.kidsmatter.edu.au
Contents
Component 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 .......................................................................... 7 Mental health in early childhood ................................................................................................................ 7 Mental health difficulties in early childhood ............................................................................................... 9 Recognising difficulties in early childhood ............................................................................................... 10 Do early mental health difficulties persist? .............................................................................................. 13 An inclusive and accepting environment assists those experiencing mental health difficulties .............. 14
Responding to children who may be experiencing mental health difficulties .................................... 16 Early intervention results in better outcomes for mental health............................................................... 16 ECEC services are in a unique position to support children’s mental health .......................................... 17 How can ECEC services promote early intervention for mental health difficulties? ................................ 18 What can ECEC services do to address the needs of children who may be experiencing mental health difficulties? ............................................................................................................................................... 19 Encouraging help seeking ....................................................................................................................... 19 Increasing collaboration between families, health professionals and ECECs ......................................... 21 Developing partnerships with external agencies ..................................................................................... 22
Summary and Implications for Practice .................................................................................................. 23
References 24
KidsMatter Early Childhood Component 4 Literature Review 4
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KidsMatter Early Childhood Component 4 Literature Review 5
www.kidsmatter.edu.au
Component 4: Helping children who
are experiencing mental health
difficulties
Background Information on KidsMatter Early Childhood
KidsMatter 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, the Australian Psychological Society 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.
KidsMatter Early Childhood Component 4 Literature Review 6
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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.
KidsMatter Early Childhood Component 4 Literature Review 7
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Helping children who are experiencing
mental health difficulties
DURING 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 childhood
Researchers 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:
KidsMatter Early Childhood Component 4 Literature Review 8
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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
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.
KidsMatter Early Childhood Component 4 Literature Review 9
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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 childhood
The 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
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
KidsMatter Early Childhood Component 4 Literature Review 10
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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 childhood
Research 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,
KidsMatter Early Childhood Component 4 Literature Review 11
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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
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
A significant factor in recognising children who may be experiencing mental
health difficulties is the persistence and frequency of particular behaviours.
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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
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,
Preschool children with major
depressive disorder are more likely
to demonstrate sadness, irritability,
somatic complaints and guilt than
older children.
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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
Without early intervention, mental
health difficulties evident in early
childhood can become significant
mental health problems later in life
KidsMatter Early Childhood Component 4 Literature Review 14
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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
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
Stigma is a perception which
identifies people as different due to
a characteristic considered to be
undesirable by the general
community.
KidsMatter Early Childhood Component 4 Literature Review 15
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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
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
Professional development and reflective practice for early childhood staff is
important in developing a non-judgemental attitude towards mental illness
KidsMatter Early Childhood Component 4 Literature Review 16
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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
Responding to children who may be experiencing mental
health difficulties
Early intervention results in better outcomes for mental health
Early 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
The quality of early
attachment relationships
significantly influences the
developing brain.
KidsMatter Early Childhood Component 4 Literature Review 17
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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
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.
The most successful early
intervention strategies have been
built on a foundation of successful
parent-staff relationships.
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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 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
Working together with children, families, mental health agencies and
organisations helps facilitate early mental health intervention and
treatment.
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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
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
The trust and respect developed
through the partnership between
families and staff also plays an
important role when seeking
external assistance.
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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.
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
Social support has a significant impact on help seeking and assisting
families living with mental illness.
KidsMatter Early Childhood Component 4 Literature Review 21
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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 ECECs
Research 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
A ‘help seeking policy’ can be a
good way to communicate the
importance and value of seeking
help.
KidsMatter Early Childhood Component 4 Literature Review 22
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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 agencies
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 More than half of children who have received mental health
support have been referred through the education sector, indicating that this is an
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
KidsMatter Early Childhood Component 4 Literature Review 23
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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.
KidsMatter Early Childhood Component 4 Literature Review 24
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