Meeting The Mental Health Needs of Young Children
By Diane M. Misch, M.D.
Illinois DocAssist Consultant
Director of The Young Child Clinic at UICMedicalCenter
Primary care providers are the first and often the only medically trained professionals that have contact with young children in a rural setting. Therefore it is important for PCPs to recognize behavioral and emotional problems early and understand the implications.
In normal conditions children under the age of six years old have the capacity to experience, regulate, and express emotions, form close and secure relationships, explore the environment, learn, and to do this within the context of a family, community, and cultural expectations. When problems are encountered, it is prudent to watch, gather further data, and provide general parenting/developmental information to caregivers. However, sometimes this is not enough, and the next step you take as a PCP may be influenced by your own beliefs on behavioral health.
Is it reasonable to think of young children as having mental health problems or does it make more sense to think about them as being at risk for problems later? The answer is yes to both questions. Young children can and do develop mental health disorders. Some are unique to the age group as in reactive attachment disorder, feeding and elimination problems. Some are the same as in older age groups like ADHD, anxiety, and, yes, mood disorders such as depression. Some may be syndromes that later develop into disorders, such as Schizophrenia. The field of young child psychopathology is relatively new, but there is sound research supporting the idea that mental illness affects the young as well as the old.
Understanding that mental illness does not occurabruptly when children reach grade school age, adolescence, or early adulthood, have important implications. Prevention, detection, and intervention during the earliest years can change the trajectory of human lives.
How can disorders be identified given that young children have a limited number of behaviors to express themselves and little to no verbal skills? Well evidence suggests that the way psychopathology is expressed depends on the types of relationships young children have with their caregivers. (Zeanah et al., 1997) So the first area to evaluate is the child’s quality of close relationships.
Caregiver passivity, intrusiveness, poor attunement, abuse, and neglect will impair development of the right frontal lobe which is the predominate part of the brain that grows during the first years of life. Right frontal lobe dysfunction manifests as inattention, impulsivity, and poor judgment as children grow.
Maternal depression is associated with less activity in the left frontal lobe of young children. Dysfunction in this area of the brain is related to predominantly negative affect (crying, irritability, proclivity towards over-stimulation, lack of reciprocity during interactions) and later learning difficulties, sad affect, and a predisposition to negatively biased perceptions.
Complications from prematurity or adverse temperament traits have better outcomes in children with accommodating caregivers. For example, a study demonstrated that supportive relationships had positive effects on children who underwent prenatal stress. Their fearfulness scores at 17 months of age were significantly moderated by good caregiver relationships while controlling for postnatal stress, obstetric, social, and demographic factors.
When looking at the quality of the relationships, it is also important to understand that young children may express symptoms in the presence of one caregiver but not another (Zeanah, Bakshi, Boris, & Lieberman, 2000)This does not mean symptoms are caused by a particular caregiver or that aspecific child does not have a pervasive problem. A child will respond differently depending on the type of environment provided. Due to the plasticity of the young brain, behavior problems can be minimized or maximized given the circumstances. Recognizing that young children with underlying emotional or behavior problems do not alwaysdisplay symptoms in every context of their lives can help PCPs remain mindful of early psychopathology rather than dismiss it as a transient or limitedproblem.
The next step in identifying psychopathology in young children is determining if the symptoms are within the scope of normal development (perhaps transiently or chronically at the outer range), a sign of developmental delay (behind for chronologic age but normal for younger stages of development), or a sign of deviance (abnormal under any circumstances).
Finally, the last step should be determining whether or not a given child has sufficient distress or dysfunction in multiple areas of life to require intervention beyond general parent education. If the answer is yes, than it is time for psychiatric consultation through Illinois DocAssist. This is a state funded service available at no cost to PCPs and clinicians serving HFS enrolled children under 21 years of age.
Contact information is:
DOCASSIST@ psych.uic.edu
1-866-986-2778
Fax: 1-866-986-2778
If the child is 0-3 years old, Early Intervention can evaluate and provide services for families of an infant or toddler with a disability or a developmental delay. In some cases the program can help families with very young children who are at risk of being delayed. For more information or to make a referral, call Child and Family Connections at 1-800-323-4769 to find the local CFC office in your area.