KidsMatter Early Childhood Component 4 Literature Review

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.



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





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.



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 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:



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.



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



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,



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.



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.



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



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.



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



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.



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.



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.



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.



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.



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.



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



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.



References 1. Shonkoff JP, Phillips DA, eds. From neurons to neighborhoods: The science of

early childhood development. Washington: National Academy Press; 2000.

2. National Scientific Council on the Developing Child. Mental health problems in early

childhood can impair learning and behavior for life. 2008.

http://developingchild.harvard.edu/index.php/resources/reports_and_working_paper

s/. Accessed 24 February 2012.

3. Commonwealth of Australia. LIFE: Living is for Everyone - A framework for

prevention of suicide and self-harm in Australia. Canberra: Department of Health

and Aging;2008.

4. Perry BD, Kaufmann RK, Knitzer J. Social and emotional health in early childhood:

Building bridges between services and systems. Baltimore, MD: Paul H Brookes

Publishing; 2007.

5. Zeanah Jnr CH, Zeanah PD. The scope of infant mental health. In: Zeanah Jnr CH,

ed. Handbook of Infant Mental Health. 3rd ed. New York: The Guilford Press;

2009:5-21.

6. Zero To Three. What is infant mental health? Washington: Zero To Three; 2002.

7. Bronfenbrenner U, Morris PA. The Bioecological Model of Human Development. In:

Lerner RM, Damon W, eds. Handbook of child psychology (6th ed ): Vol 1,

Theoretical models of human development. Hoboken, NJ: John Wiley & Sons Inc;

2006:793-828.

8. Sanson A, Oberklaid F, Pedlow R, Prior M. Risk indicators: Assessment of infancy

predictors of pre-school behavioural maladjustment. Journal of Child Psychology &

Psychiatry & Allied Disciplines. 1991;32(4):609-626.

9. Currenti S. Understanding and determining the etiology of autism. Cellular and

Molecular Neurobiology. 2010;30:161-171.

10. Spencer TJ, Biederman J, Mick E. Attention-deficit/hyperactivity disorder:

Diagnosis, lifespan, comorbidities, and neurobiology. Ambulatory Pediatrics.

2007;7(1S):73-81.

11. Strathearn L. The elusive etiology of autism: Nature and nurture? Frontiers in

Behavioural Neuroscience. 2009;3(11).

12. Luby JL, Belden A, Spitznagel E. Risk factors for preschool depression: The

mediating role of early stressful life events. Journal of Child Psychology and

Psychiatry. 2006;47(12):1292–1298.

13. Robinson G, Silburn SR, Arney F. A population approach to early childhood

services: Implementation for outcomes. 2011.

http://www.det.nt.gov.au/__data/assets/pdf_file/0010/19486/PopulationApproachTo

EarlyChildhoodServices.pdf. Accessed 23 February 2012.

14. Côté SM, Boivin M, Liu X, Nagin DS, Zoccolillo M, Tremblay RE. Depression and

anxiety symptoms: Onset, developmental course and risk factors during early

http://developingchild.harvard.edu/index.php/resources/reports_and_working_papers/


http://www.det.nt.gov.au/__data/assets/pdf_file/0010/19486/PopulationApproachToEarlyChildhoodServices.pdf

http://www.det.nt.gov.au/__data/assets/pdf_file/0010/19486/PopulationApproachToEarlyChildhoodServices.pdf



childhood. The Journal of Child Psychology and Psychiatry. 2009;50(10):1201-

1208.

15. Degnan K, Almas AN, Fox NA. Temperament and the environment in the etiology of

childhood anxiety. Journal of Child Psychology and Psychiatry. 2010;51(4):497-517.

16. Keren M, Tyano S. Depression in Infancy. Child and Adolescent Psychiatric Clinics

of North America. 2006;15(4):883–897.

17. Davis E, Sawyer MG, Lo SK, Priest N, Wake M. Socioeconomic risk factors for

mental health problems in 4-5-year-old children: Australian population study.

Academic Pediatrics. 2010;10(1):41-47.

18. Fox RA, Holtz CA. Treatment outcomes for toddlers with behaviour problems from

families in poverty. Child and Adolescent Mental Health. 2009;14(4):183-189.

19. Spence SH, Najman JM, Bor W, O'Callaghan M, Williams GM. Maternal anxiety

and depression, poverty and marital relationship factors during early childhood as

predictors of anxiety and depressive symptoms in adolescents. Journal of child

Psychology and Psychiatry. 2002;43(4):457-469.

20. Pavuluri MN, Luk S, Clarkson J, McGee R. A community study of preschool

behaviour disorder in New Zealand. Australian and New Zealand Journal of

Psychiatry. 1995;29:454-462.

21. Douglas KR, Chan G, Gelernter J, et al. Adverse childhood events as risk factors

for substance dependence: Partial mediation by mood and anxiety disorders.

Addictive Behaviours. 2010;35:7-13.

22. Wainwright NWJ, Surtees PG. Childhood adversity, gender and depression over the

life-course. Journal of Affective Disorders. 2002;72:33-44.

23. Commonwealth Department of Health and Aged Care. Promotion, prevention and

early intervention for mental health - A monograph. In: Mental Health Special

Programs Branch, ed. Canberra: Author; 2000.

24. Kay-Lambkin F, Kemp E, Stafford K, Hazell T. Mental health promotion and early

intervention in early childhood and primary school settings: A review. Journal of

Student Wellbeing. 2007;1(1):31-56.

25. Maselko J, Kubzansky L, Lipsitt L, Buka SL. Mother’s affection at 8 months predicts

emotional distress in adulthood. Journal of Epidemiology and Community Health.

2010;July:1-5.

26. Vermeer HJ, Bakermans-Kranenburg MJ. Attachment to mother and nonmaternal

care: Bridging the gap. Attachment & Human Development. 2008;10(3):263-273.

27. Field T. Postpartum depression effects on early interactions, parenting, and safety

practices: A review. Infant Behavior & Development. 2010;33(1):1-6.

28. Schrepferman LM, Eby J, Snyder J, Stropes J. Early affiliation and social

engagement with peers: Prospective risk and protective factors for childhood

depressive behaviors. Journal of Emotional & Behavioral Disorders. 2006;14(1):50-

61.

29. Williams LR, Degnan K, Perez-Edgar KE, et al. Impact of behavioral inhibition and

parenting style on internalizing and externalizing problems from early childhood

through adolescence. Journal of Abnormal Child Psychology. 2009;37:1063–1075.



30. Wille N, Bettge S, Ravens-Sieberer U, BELLA Study Group. Risk and protective

factors for children's and adolescents' mental health: Results from the BELLA study.

European Child and Adolescent Psychiatry. 2008;17:133-147.

31. Ylvisaker M. Apprenticeship in self-regulation: Supports and interventions for

individuals with self-regulatory impairments. Pediatric rehabilitation. 2009;12(5):370.

32. U.S Congress Office of Technology Assessment. Children's mental health:

problems and services - A background paper. Washington D.C: U.S Government

Printing Office;1986.

33. Zeanah Jnr CH. Handbook of Infant Mental Health. 3rd ed. New York: The Guilford

Press; 2009.

34. Mann TL, Powers S, Boss J, Fraga LM. Infusing mental health supports and

services into infant and toddler environments. In: Perry DF, Kaufmann RK, Knitzer

J, eds. Social and emotional health in early childhood. Maryland: Paul H. Brookes

Publishing Company; 2007:257-280.

35. Australian Institute of Health and Welfare (AIHW). A picture of Australia's children

2009. Cat No. PHE 112. Canberra: Australian Institute of Health and Welfare 2009.

36. Centre for Community Child Health, Telethon Institute for Child Health Research. A

Snapshot of Early Childhood Development in Australia – AEDI National Report

2009. Canberra: Australian Government;2009.

37. Sawyer MG, Arney FM, Baghurst PA, et al. The mental health of young people in

Australia. Canberra: Mental Health and Special Programs Branch, Commonwealth

Department of Health and Aged Care; 2000.

38. Carter AS, Wagmiller RJ, Gray SAO, McCarthy KJ, Horwitz SM, Briggs-Gowan MJ.

Prevalence of DSM-IV disorder in a representative, healthy birth cohort at school

entry: Sociodemographic risks and social adaptation. Journal of the American

Academy of Child & Adolescent Psychiatry 2010;49(7):686-698.

39. Costello E, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development

of psychiatric disorders in childhood and adolescence. Archives of General

Psychiatry. Aug 2003;60(8):837-844.

40. Egger HL. Psychiatric assessment of young children. Child and Adolescent

Psychiatric Clinics of North America. 2009;18(3):559-580.

41. Skovgaard AM, Houmann T, Christiansen E, et al. The prevalence of mental health

problems in children 1½ years of age – the Copenhagen Child Cohort 2000. Journal

of Child Psychology and Psychiatry. 2007;48(1):62-70.

42. Angold A, Egger HL. Preschool psychopathology: Lessons for the lifespan. Journal

of Child Psychology and Psychiatry. 2007;48(10):961-966.

43. Cohen P, Provet A, Jones M. The prevalence of emotional and behavioral disorders

in childhood and adolescence. In: Levin B, Petrila J, eds. Mental health services: A

public health perspective. New York: Oxford University Press; 1996:193-209.

44. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime

prevalence and age-of-onset distributions of DSM–IV disorders in the National

Comorbidity Survey Replication. Archives of General Psychiatry. 2005;62:593–602.



45. Rapoport J, Gogtay N. Brain neuroplasticity in healthy, hyperactive and psychotic

children: Insights from neuroimaging. Neuropsychopharmacology reviews.

2008;33:181-197.

46. Perry BD, Pollard RA, Blakley TL, Baker WL, Vigilante D. Childhood trauma, the

neurobiology of adaptation, and 'use-dependent' development of the brain: How

'states' become 'traits.'. Infant Mental Health Journal. 1995;16(4):271-291.

47. Donohue PJ, Falk B, Provet AG. Promoting social- emotional development in young

children: Mental health supports in early childhood. In: Perry DF, Kaufmann RK,

Knitzer J, eds. Social and emotional health in early childhood: Building bridges

between services and systems. Maryland: Paul H. Brooks Publishing Company;

2007:281-312.

48. Thompson RA, Raikes HA. The social and emotional foundations of school

readiness. In: Perry DF, Kaufmann RK, Knitzer J, eds. Social and emotional health

in early childhood. Maryland: Paul H. Brookes Publishing Company; 2007:13-36.

49. DelCarmen-Wiggins R, Carter A. Handbook of infant, toddler and preschool mental

health assessment. New York: Oxford University Press, Inc.; 2004.

50. Bruder MB. Early childhood intervention: A promise to children and families for their

future. Exceptional children. 2010;76(3):339-355.

51. Durlak JA, Wells AM. Evaluation of indicated preventative intervention (secondary

prevention) mental health programs for children and adolescents. American Journal

of Community Psychology. 1998;26(5):775-802.

52. Lecuyer R. What theoretical basis for intervention with very young children? 27th

International Congress of Applied Psychology. Melbourne 2010.

53. Egger HL, Angold A. Common emotional and behavioral disorders in preschool

children: Presentation, nosology, and epidemiology. Journal of Child Psychology

and Psychiatry. 2006;47(3/4):313-337.

54. Degani GA, Breinbauer C, Roosevelt JD, Porges S, Greenspan S. Prediction of

childhood problems at three years in children experience disorders of regulation

during infancy. Infant Mental Health Journal. 2000;21(3):156-175.

55. Anderson P. Assessment and development of executive function (EF) during

childhood. Child Neuropsychology: A Journal On Normal And Abnormal

Development In Childhood And Adolescence. 2002;8(2):71-82.

56. Smidts DP, Oosterlaan J. How common are symptoms of ADHD in typically

developing preschoolers? A study on prevalence rates and prenatal/demographic

risk factors. A Journal Devoted to the Study of the Nervous System and Behavior.

2007;43:710-717.

57. Lavigne JV, Binns H, Christoffel KK, et al. Behavioural and emotional problems

among preschool children in pediatric primary care: prevalence and pediatricians'

recognition. Pediatrics. 1993;91(3):649-655.

58. Donovan CL, Spence SH. Prevention of childhood anxiety disorders. Clinical

Psychology Review. 2000;20(4):509-531.

59. Schmidt NB, Keough ME, Mitchell MA, et al. Anxiety sensitivity: Prospective

prediction of anxiety among early adolescents. Journal of Anxiety Disorders.

2010;24(5):503-508.



60. Bayer JK, Hiscock H, Ukoumunne OC, Price A, Wake M. Early childhood aetiology

of mental health problems: A longitudinal population-based study. Journal of Child


61. Warren SL, Huston L, Egeland B, Sroufe LA. Child and adolescent anxiety

disorders and early attachment. Journal of the American Academy of Child and

Adolescent Psychiatry. 1997;36(5):637-644.

62. Spence SH, Rapee R, McDonald C, Ingram M. The structure of anxiety symptoms

among preschoolers. Behaviour Research and Therapy. 2001;39:1293-1316.

63. Luby JL, Heffelfinger AK, Mrakotsky C, et al. The clinical picture of depression in

preschool children. Journal of American Academy of Child & Adolescent Psychiatry.

2003;42(3):340-348.

64. Luby JL, Belden A, Sullivan J, Hayen R, McCadney A, Spitznagel E. Shame and

guilt in preschool depression: Evidence of elevations in self-conscious emotions in

depression as early as age 3. The Journal of Child Psychology and Psychiatry.

2009;50(9):1156-1166.

65. Luby JL, Belden AC, Pautsch J, Si X, Spitznagel E. The clinical significance of

preschool depression: Impairment in functioning and clinical markers of the

disorder. Journal of Affective Disorders. 2009;112(1-3):111-119.

66. Stalets MM, Luby JL. Preschool depression. Child and Adolescent Psychiatric

Clinics of North America. 2006;15(4):899-917.

67. Baranek G. Autism during infancy: A retrospective video analysis of sensory-motor

and social behaviors at 9-12 months of age. Journal of Autism and Developmental

Disorders. 1999;29(3):213-224.

68. Osterling J, Dawson G. Early recognition of children with autism: A study of first

birthday home videotapes. Journal of Autism and Developmental Disorders.

1994;24(3):247-257.

69. Filipek PA, Accardo PJ, Baranek GT, et al. The screening and diagnosis of autistic

spectrum disorders. Journal of Autism and Developmental Disorders. 1999;29(6).

70. Howlin P, Asgharian A. The diagnosis of autism and asperger syndrome: Findings

from a survey of 770 families. Developmental Medicine & Child Neurology.

1999;41:834-839.

71. Mandell DS, Novak M, Zubritsky CD. Factors associated with age of diagnosis

among children with autism spectrum disorders. Pediatrics. 2005;116(6):1480-1486.

72. Weyers C. Post-traumatic stress disorder in children. Continuing medical education.

2004;22(8):457-459.

73. Perry B, Pollard R. Homeostasis, stress, trauma and adaptation: A

neurodevelopmental view of childhood trauma. Child and Adolescent Psychiatric

Clinics of North America. 1998;7(1):33-51.

74. Terr LC. Childhood traumas: An outline and overview. American Journal of

Psychiatry. 1991;148(1):10-20.

75. Thomas JM. Traumatic stress disorder presents as hyperactivity and disruptive

behaviour: Case presentation, diagnoses and treatment. Infant Mental Health

Journal. 1995;16(4):306-317.



76. Kaminer D, Seedat S, Stein DJ. Post-traumatic stress disorder in children. World

Psychiatry. 2005;4(2):121-125.

77. National Scientific Council on the Developing Child. Excessive stress disrupts the

architecture of the developing brain: Working paper No. 3. 2005.

http://developingchild.harvard.edu/index.php/resources/reports_and_working_paper

s/. Accessed 23 February 2012.

78. Rutter M, Kim-Cohen J, Maughan B. Continuities and discontinuities in

psychopathology between childhood and adult life. Journal of Child Psychology and

Psychiatry. 2006;47(3/4):276–295.

79. Richman N, Lansdown R. Problems of preschool children. New York: John Wiley &

Sons; 1998.

80. Prior MR, Sanson A, Smart D, Oberklaid F. Pathways from infancy to adolescence:

Australian Temperament Project 1983-2000. Melbourne: Australian Institute of

Family Studies - Commonwealth of Australia; 2000.

81. Briggs-Gowan MJ, Carter AS, Bosson-Heenan J, Guyer AE, Horwitz SM. Are infant-

toddler social-emotional and behavioral problems transient? Journal of the

American Academy of Child & Adolescent Psychiatry. 2006;45(7):849-858.

82. Briggs-Gowan MJ, Carter AS. Social-emotional screening status in early childhood

predicts elementary school outcomes. Official Journal of the American Acadamy of

Pediatrics. 2008;121:957-962.

83. Honkinen P, Aromaa M, Suominen S, et al. Early childhood psychological problems

predict a poor sense of coherence in adolescents: A 15-year follow-up study.

Journal of Health Psychology. 2009;14(4):587-600.

84. Pihlakoski L, Aromaa M, Sourander A, Rautava P, Helenius H, Sillanpaa M. Use of

and need for professional help for emotional and behavioural problems among

preadolescents: A prospective cohort study of 3- to 12- year old children. Journal of

the American Academy of Child & Adolescent Psychiatry. 2004;43(8):974-983.

85. Bor W, McGee TR, Fagan AA. Early risk factors for adolescent antisocial behaviour:

An Australian longitudinal study. Australian and New Zealand Journal of Psychiatry.

2004;38(5):365-372.

86. Campbell S, Ewing L. Follow-up of hard-to-manage preschoolers: Adjustment at

age 9 and predictors of continuing symptoms. Journal of Child Psychiatry.

1990;31(6):871-889.

87. Egeland B, Kalkoske M, Gottesman N, Erickson MF. Preschool behaviour

problems: Stability and factors accounting for change. Journal of Child Psychology

and Psychiatry. 1990;31(6):891-909.

88. Newacheck P, Strickland B, Shonkoff J, et al. An epidemiological profile of children

with special health care needs. Pediatrics. 1998;102(1):117-123.

89. Reid MJ, Webster-Stratton C, Hammond M. Follow-up of children who received the

Incredible Years intervention for oppositionaI-defiant disorder: Maintenance and

prediction of 2-year outcome. Behavior Therapy. 2003;34:471-491.

90. Bhardwaj A, Goodyer IM. Depression and allied illness in children and adolescents:

Basic facts. Psychoanalytic Psychotherapy. 2009;23(3):176-184.





91. Meyer SE, Carlson GA, Youngstrom E, et al. Long-term outcomes of youth who

manifested the CBCL-Pediatric Bipolar Disorder phenotype during childhood and/or

adolescence. Journal of Affective Disorders. 2009;113:227-235.

92. Simonoff E, Elander J, Holmshaw J, Pickles A, Murray R, Rutter M. Predictors of

antisocial personality. British Journal of Psychiatry. 2004;184:118-127.

93. Sourander A, Jensen P, Davies M, et al. Who is at greatest risk of adverse long-

term outcomes? The Finnish from a boy to a man study. Journal of the American

Academy of Child and Adolescent Psychiatry. 2007;46(9):1148-1161.

94. Mesman J, Bongers I, Koot H. Preschool developmental pathways to preadolescent

internalizing and externalizing problems. Journal of Child Psychology & Psychiatry

2001;42(5):679-689.

95. Dunn V, Goodyer IM. Longitudinal investigation into childhood and adolescence-

onset depression: Psychiatric outcome in early adulthood. British Journal of

Psychiatry. 2006;188:216-222.

96. Tsao CL, Tummala A, Roberts LW. Stigma in mental health care. Academic

Psychiatry. 2008;32(2):70-72.

97. Link BG, Phelan JC. Conceptualizing stigma. Annual Review of Sociology.

2001;27:363-385.

98. Phelan JC, Link BG, Stueve A, Pescosolido BA. Public conceptions of mental

illness in 1950 and 1996: What is mental illness and is it to be feared? Journal of

Health and Social Behavior. 2000;41(2):188-207.

99. World Health Organization. Investing in mental health. Geneva: Author;2003.

100. Gray AJ. Stigma in psychiatry. Journal of the Royal Society of Medicine.

2002;95:72-76.

101. Corrigan PW. How clinical diagnosis might exacerbate the stigma of mental illness.

National Association of Social Workers. 2007;52(1):31-39.

102. Barbour RS, Stanley N, Penhale B, Holden S. Assessing risk: Professional

perspectives on work involving mental health and child care services. Journal of

Interprofessional Care. 2002;16(4):323-334.

103. Larson JE, Corrigan PW. The stigma of families with mental illness. Academic

Psychiatry. 2008;32(2):87-91.

104. Pescosolido B, Jensen P, Martin KJ, Perry B, Olafsdottir S, Fettes DL. Public

knowledge and assessment of child mental health problems: Findings from the

national stigma study-children. Journal of the American Academy of Child and

Adolescent Psychiatry. 2008;47(3):339-349.

105. Cole N. Depression awareness: Community-based approach. Australian

Psychologist. 2007;42(2):161-166.

106. World Health Organization. Promoting mental health: Concepts, emerging evidence

and practice: Summary report. Vienna: World Health Organization, Department of

Mental Health and Substance Abuse, Victorian Health Promotion Foundation

(VicHealth), University of Melbourne;2004.

107. Jorm AF. Mental health literacy: Public knowledge and beliefs about mental

disorders. The British Journal of Psychiatry. 2000;177:396-401.



108. Second National Mental Health Plan Evaluation Steering Committee. Evaluation of

the Second National Mental Health Plan 1998 - 2003. Canberra: Commonwealth

Department of Health and Aging;2003.

109. Bussing R, Zima BT, Gary FA, Garvan CW. Barriers to detection, help-seeking, and

service use for children with ADHD Symptoms. Journal of Behavioral Health

Services & Research. 2003;30(2):176.

110. Lipman EL, Boyle MH. Barriers to services promoting child emotional, behavioural,

and social health. In: Tremblay RE, Barr RG, Peters RD, eds. Encyclopedia on

early childhood development. Montreal, Quebec, Canada: Centre of Excellence for

Early Childhood Development; 2003.

111. Vogel DL, Wester SR. To seek help or not to seek help: The risks of self-disclosure.

Journal of Counseling Psychology. 2003;50(3):351.

112. Sawyer MG, Kosky RJ, Graetz BW, Arney F, Zubrick SR, Baghurst P. The National

Survey of Mental Health and Wellbeing: The child and adolescent component.

Australian and New Zealand Journal of Psychiatry. 2000;34(2):214-220.

113. Huang LN, Stroul B, Friedman R, et al. Transforming mental health care for children

and their families. American Psychologist. 2005;60(6):615-627.

114. Wayne W, Alkon A, Buchanan E. Creating a state strategic plan for integrating

services for children using multiple qualitative methods. Maternal And Child Health

Journal. 2008;12(1):15-23.

115. Raviv A, Sharvit K, Raviv A, Rosenblat-Stein S. Mothers’ and fathers’ reluctance to

seek psychological help for their children. Journal of Child and Family Studies.

2009;18:151-162.

116. Shanley DC, Reid GJ, Evans B. How parents seek help for children with mental

health problems. Administration and Policy in Mental Health and Mental Health

Services Research. 2008;35(3):135-146.

117. Commonwealth Department of Health and Aged Care. National Action Plan for

Depression. Canberra: Mental Health and Special Programs Branch;2000.

118. Buila SMD. Using the media to enhance well-being and mental health. Rural

Society. 2009;19(4):363-367.

119. Early Childhood Australia, Secretariat of National Aboriginal and Islander Child

Care. COAG Mental Health Early Intervention Measure: Early childhood

component. Study to scope potential service delivery. Canberra: Department of

Health and Ageing;2007.

120. Rothi D, Leavey G, Best R. On the front-line: Teachers as active observers of

pupils’ mental health. Teaching and Teacher Education. 2008;24(5):1217-1231.

121. Sims M, Davis E, Davies B, et al. Mental health promotion in childcare centres:

Childcare teachers understanding of child and parental mental health. in press.

122. Block AW, Block SR. Strengthening social work approaches through advancing

knowledge of early childhood intervention. Child & Adolescent Social Work Journal.

2002;19(3):191-208.

123. Australian Institute of Family Studies. Prevention and early intervention in

strengthening families and relationships: Challenges and implications. 2008.



http://www.aifs.gov.au/afrc/pubs/issues/issues2/issues2.pdf. Accessed 24 February

2012.

124. Zeanah P, Stafford B, Nagle G, Rice T. Addressing social-emotional development

and infant mental health in early childhood systems. Los Angeles: National Center

for Infant and Early Childhood Health Policy 2005.

125. Robinson E, Parker R. Prevention and early intervention in strengthening families

and relationships: Challenges and implications Australian Family Relationships

Clearinghouse Issues. 2008;2.

http://www.aifs.gov.au/afrc/pubs/issues/issues2/issues2.pdf. Accessed 24 February

2012.

126. National Scientific Council on the Developing Child. The foundations of lifelong

health are built in early childhood. Cambridge: The Center on the Developing Child

at Harvard University;2010.

127. Owen MT, Klausli JF, Mata-Otero A, Caughy MOB. Relationship-focused child care

practices: Quality of care and child outcomes for children in poverty. Early

Education & Development. 2008;19(2):302–329.

128. Schore AN. Effects of a secure attachment relationship on right brain development,

affect regulation, and infant mental health. Infant Mental Health Journal.

2001;22(1):7-66.

129. Egeland B. Attachment based intervention and prevention programs for young

children. In: Tremblay RE, Barr RG, Peters RD, eds. Encyclopedia on early

childhood development. Montreal: Centre of Excellence for Early Childhood

Development; 2004:1-7.

130. Marvin R, Cooper G, Hoffman K, Powell B. The Circle of Security project:

Attachment-based intervention with caregiver-pre-school child dyads. Attachment &

Human Development. 2002;4(1):107-124.

131. Seth-Smith F, Levi N, Pratt R, Fonagy P, Jaffey D. Do nurture groups improve the

social emotional and behavioural functioning of at risk children? Educational and

Child Psychology. 2010;27(1):23-34.

132. Scott K, Lee A. Beyond the ‘classic’ nurture group model: an evaluation of part-time

and cross-age nurture groups in a Scottish local authority. Support for Learning.

2009;24(15-10).

133. Havinghurst S, Harley A. Tuning in to Kids Program. In: Melbourne Uo, ed2009.

134. Compton SN, Burns BJ, Egger HL, Robertson E. Review of the evidence base for

treatment of childhood psychopathology: Internalizing disorders. Journal of

Consulting and Clinical Psychology. 2002;70(6):1240–1266.

135. Nevo GA, Manassis K. Outcomes for treated anxious children: A critical review of

long-term-follow-up studies. Depression and Anxiety. 2009;26:650-660.

136. Brandt MA. An investigation of the efficacy of play therapy with young children.

Dissertation prepared for the Degree of Doctor of Philosophy: University of North

Texas; 1999.

137. Bayat M. Nondirective play-therapy for children with internalized problems. Journal

of Iranian Psychologists. 2008;4(15):16-17.

http://www.aifs.gov.au/afrc/pubs/issues/issues2/issues2.pdf

http://www.aifs.gov.au/afrc/pubs/issues/issues2/issues2.pdf



138. Bratton SC, Ray D, Rhine T, Jones L. The efficacy of play therapy with children: A

meta-analytic review of treatment outcomes. Professional Psychology: Research

and Practice. 2005;36(4):376-390.

139. LeBlanc M, Ritchie M. A meta-analysis of play therapy outcomes. Counselling

Psychology Quarterly. 2001;14(2):149-163.

140. Sawyer MG, Arney FM, Baghurst PA, et al. The mental health of young people in

Australia: Key findings from the child and adolescent component of the national

survey of mental health and well-being. Australian and New Zealand Journal of

Psychiatry. 2001;35:806-814.

141. Watson J, White A, Taplin S, Huntsman L. Prevention and early intervention:

Literature review. . Retrieved from NSW: NSW Centre for Parenting and Research;

2005.

142. Bayer JK, Hiscock H, Morton-Allen E, Ukoumunne OC, Wake M. Prevention of

mental health problems: Rationale for a universal approach. Archives Of Disease In

Childhood 2006;92(1):34-38.

143. Steering Committee for the Review of Government Service Provision. Report on

Government Services 2010. Canberra: Productivity Commission;2010.

144. Vimpani G. The health and well-being of Australian children and young people 0-20

years: Where have we come from: Where are we going? . Paper presented at:

National Foundation for Australian Women workshop; April, 2005; Forrest, NSW.

145. Evangelista N, McLellan MJ. The Zero to Three Diagnostic System: A framework for

considering emotional and behavioral problems in young children. School

Psychology Review. 2004;33(1):159-173.

146. Jackson A, King AR. Gender differences in the effects of oppositional behavior on

teacher ratings of ADHD symptoms. Journal of Abnormal Child Psychology.

2004;32(2):215–224.

147. Silins H, Mathews C, Lokan J, Hudson M. Developing mentally healthy children. SA:

The Australian College of Educators;2007.

148. Zeanah CH, Zeanah PD. Three decades of growth in infant mental health. Zero to

Three. 2009;30(2):22-27.

149. Emde RN, Bertacchi J, Mann TL. Organizational environments that support mental

health. Zero to Three. 2001;22(1):67-69.

150. Chazan-Cohen R, Jerald J, Stark DR. A commitment to supporting the mental

health of our youngest children. Zero to Three. 2001;22(1):4-12.

151. Raphael B. Promoting the mental health and wellbeing of children and young

people. Discussion paper: Key principles and directions. Canberra: Department of

Health and Aged Care, National Mental Health Working Group; 2000.

152. Squires J. The importance of early identification of social and emotional difficulties

in preschool children. Eugene, Oregon: University of Oregon; 2003.

153. Farrell P, Travers T. A healthy start: Mental health promotion in early childhood

settings. Australian e-Journal for the Advancement of Mental Health. 2005;4(2):1-

10.

154. Sanders MR. Parenting interventions and the prevention of serious mental health

problems in children. The Medical Journal of Australia. 2002;177 Supp:S87-S92.



155. Hinson JA, Swanson JL. Willingness to seek help as a function of self-disclosure

and problem severity. Journal of Counseling & Development. 1993;71:465-470

156. Sayal K. Pathways to care for children with mental health problems. Journal of Child


157. Stiffman AR, Pescosolido B, Cabassa LJ. Building a model to understand youth

service access: The gateway provider model. Mental Health Services Research.

2004;6:189–198.

158. Komiya N, Good GE, Sherrod NB. Emotional openness as a predictor of college

students' attitudes toward seeking psychological help. Journal of Counseling

Psychology. 2000;47(1):138.

159. McCarthy J. Helping counselor trainees overcome barriers to seeking help. Journal

of Humanistic Counseling, Education & Development. 2008;47(1):71-81.

160. Letvak S. The importance of social support for rural mental health. Issues in Mental

Health Nursing. 2002;23:249–261.

161. Carter AS, Briggs-Gowan MJ, Ornstein Davis N. Assesment of young children's

social emotional development and psychopathology: Recent advances and

recommendations for practice. Journal of Child Psychology and Psychiatry.

2004;45(1):109-134.

162. Cepeda-Benito A, Short P. Self-concealment, avoidance of psychological services,

and perceived likelihood of seeking professional help. Journal of Counseling

Psychology. 1998;45(1):58-64.

163. Pavuluri MN, Siu-Luen L, McGee R. Help-seeking for behavior problems by parents

of preschool children: A community study. Journal of the American Academy of

Child & Adolescent Psychiatry. 1996;35(2):215-222.

164. Rawlinson S, Williams DL, & Stallworth, J. The primary/secondary care interface in

child and adolescent mental health services: The relevance of burden. Current

Opinion in Psychiatry. 2000;13:389-395.

165. Prochaska JO, Velicer WF, Rossi JS, et al. Stages of change and decisional

balance for 12 problem behaviors. Health Psychology. 1994;13(1):39-46.

166. Moore T. Blazing new trails: Finding the most direct routes in early childhood

intervention. Paper presented at: Sixth Biennial National Conference of Early

Childhood Intervention Australia. 25–27 July.2004; Melbourne, Victoria.

167. Rogers R, Moore TG. The Early Years Project: Refocusing community bases

services for young children and their familes: A literature review. Parkville: Centre

for Community Child Health, Royal Children’s Hospital, in partnership with Good

Beginnings Australia;2003.

168. Priest N, Waters E. "Motor Magic": Evaluation of a community capacity-building

approach to supporting the development of preschool children (Part 2). Australian

Occupational Therapy Journal. 2007;54(2):140-148.

169. Farmer EM, Burns BJ, Phillips S, Angold A, Costello EJ. Pathways into and through

mental health services for children and adolescents. Psychiatric Services.

2003;54(1):60-66.

170. Knitzer J. Putting knowledge into policy: Toward an infant-toddler policy agenda.

Infant Mental Health Journal. 2007;28(2):237-245.



171. Knitzer J. Early childhood mental health services. In: Shonkoff JP, Meisels SJ, eds.

Handbook of early childhood intervention. Cambridge: Cambridge University Press;

2000:416-438.

172. Johnston K, Brinamen C. Mental health consultation in child care: Transforming

relationships among directors, staff and families. Washington: ZERO TO THREE;

2006.

173. Williford AP, Shelton TL. Using mental health consultation to decrease disruptive

behaviours in preschoolers: adapting an empirically-supported intervention. Journal

of Child Psychology & Psychiatry. 2008;49(2):191-200.

174. Salmon G, Cleave H, Samuel C. Development of multi-agency referral pathways for

attention-deficit hyperactivity disorder, developmental coordination disorder and

autistic spectrum disorders: Reflections on the process and suggestions for new

ways of working. Clinical Child Psychology and Psychiatry. 2006;11(1):63-81.

This resource is part of the KidsMatter Early

Childhood Initiative. The KidsMatter Early Childhood

team welcomes your feedback at


KidsMatter Early Childhood Component 4 Literature Review

Documents