Infant and Early Childhood Mental Health
Increasing attention is being placed in the medical and public space on the mental health of infants and young children. Among mental health providers, infant mental health generally refers to children 3 years of age and younger, while early childhood mental health refers to children ages 3-5. This contrasts with the pediatric community, which typically defines infants as children younger than 12 months of age. Widespread information and research regarding the importance of the prenatal period indicates that health, including mental health, begins well before birth. For infants and children, as for adults, good health isn’t just the absence of disease—it is the presence of complete, sound physical and mental health, which includes living in a safe, secure environment, with supportive and caring relationships, and having the ability to experience and enjoy the world. Infant mental health has been defined as “the young child’s capacity to experience, regulate, and express emotions, form close and secure relationships, and explore the environment and learn.” (Zero to Three, 2001) For infants and young children, good mental health means that the brain can develop and grow in a healthy way to form a strong foundation for future health, behavior, and learning.
For children to have sound mental and physical health, the adults who care for them must have supports that decrease their own stress and enable them to be emotionally available for their children. When a child experiences a stressful life event, it is the buffering relationship with an emotionally responsive, loving adult that preserves the child’s mental and physical health. When these relationships are not present, children are more likely to experience adverse effects of stress. While caregivers play an important role in decreasing stress in children, building responsive relationships alone is not sufficient. Many caregivers with young children experience distinctive challenges in life. Adding to the sources of stress felt by all caregivers, many families of color experience other substantial burdens: unequal treatment in health care, education, child welfare, and justice systems; entrenched barriers to economic advancement; and frequent indignities resulting from cultural racism. Yet these stress-inducing experiences are not inevitable. Current policies that expand access to high-quality medical care and early childhood programs provide important benefits for individual children and families. But to reduce persistent inequalities at a population level, they must be augmented by a more intentional, “upstream” focus on a broader range of socioeconomic conditions and policies. These include more equitable access to assets and opportunities in education, employment, housing, health-promoting environments, and wealth creation, among others. Improving the life prospects of all children and families—and building a sustainable society in which everyone thrives—will require new policy approaches to confront and dismantle the structural inequities that undermine the well-being of over- burdened families living in under-resourced communities.
Many interventions that build resilience in children and caregivers facing adversity (e.g., evidence-based home visiting, therapeutic foster care) can lead to better individual outcomes—and well-established public health policies (e.g., food assistance, lead screening, or regular blood pressure checks) can reduce population-level inequalities. But reducing health disparities also requires targeted strategies that address the social inequities that have historically limited opportunities for certain groups. For more information, read this brief: Moving Upstream: Confronting Racism to Open Up Children’s Potential .
The Science Behind Early Childhood Mental Health
The term “epigenetics” refers to the interaction of genes and experience, and this interaction affects childhood mental health. Genes are not destiny. Experiences, particularly those in early childhood, determine how genes are turned on and off, including genes that are involved in our mental health. The healthy development of all organs, including the brain, depends on how much and when certain genes are activated to do certain tasks. The interaction between genetic predispositions and sustained, stress-inducing experiences early in life can lay an unstable foundation for mental health that endures well into the adult years. All aspects of brain function are the result of the interaction between genes and experience. Mental health, behavior, and personality all have a genetic component, but they are all very malleable to environmental experiences.
Toxic stress can damage brain architecture and increase the likelihood that significant mental health problems will emerge either quickly or years later. Because of its enduring effects on brain development and other organ systems, toxic stress can impair school readiness, academic achievement, and both physical and mental health throughout the lifespan. Circumstances associated with significant family stress, such as persistent poverty and systemic racism, may elevate the risk of serious mental health problems. Young children who experience recurrent abuse or chronic neglect, domestic violence, or parental mental health or substance abuse problems are particularly vulnerable. The single most common factor for children who develop resilience in the face of significant adversity is at least one stable and committed relationship with a supportive parent, caregiver, or other adult.
The Clinician’s Role: Early Identification and Support Matter
Very young infants and young children can exhibit emotional and motor behaviors that are predictive in certain cases of early mental illness. Most potential mental health concerns will not become mental health problems if we respond to them early. Providing the right support early can reduce the likelihood of greater problems later. Pediatric healthcare providers are well aware that when children have mental health problems, they look different than when adults have mental health problems. Pediatric mental health issues are often labeled as “behavior problems” or noted as a child having “difficulty managing emotions.” The challenge for pediatric clinicians is identifying which children are at risk for mental health problems and which ones are simply exhibiting differences in healthy development. Because young children’s emotional well-being is tied so closely to the mental health of their parents and caregivers, understanding the environment of relationships that a child is in can help pediatricians make the distinction between who might benefit from clinician-directed support and who may be less at risk for future problems. For the pediatric clinician, this may include specific screenings related to caregiver mental health and asking families about new and ongoing sources of stress. Ultimately, the emotional and behavioral needs of infants, toddlers, and preschoolers are best met through coordinated services that focus on their full environment of relationships.
Screening Tools for Primary Care:
- The Screening Technical Assistance and Resource Center of the American Academy of Pediatrics includes a comprehensive collection of resources and information about screening tools. Here we offer a small selection of screening tools around caregiver and childhood mental health that can help facilitate conversation in clinical practice.
- Maternal depression can have an adverse effect on the developing brain in the early years. Screening for peripartum mental health concerns through the Edinburgh Postnatal Depression Scale can identify mothers who might benefit from additional support.
- The Pediatric Symptom Checklist (PSC) can be used to screen for young children at risk for mental health concerns. It is typically administered annually, in the context of the well child visit. The checklist is available in many languages and can be integrated into an electronic health record for automatic scoring.
- The Survey of Well-Being of Young Children (SWYC) is freely available and includes sections on developmental milestones, social and emotional development, and family-related risk factors.
- The Ages and Stages Questionnaires: Social Emotional (ASQ:SE) is a general psychosocial screen for children aged 6 months through 5 years, and includes items related to self-regulation, communication, and interpersonal interactions.
- The Pediatric Health Questionnaire-9 (PHQ-9) can be used to screen for depression in adolescents, a group that has experienced increased rates of mental health problems in the face of the coronavirus pandemic.
- The abbreviated PHQ-2 consists of the first two questions of the PHQ-9 and asks about depressive symptoms and anhedonia within the past two weeks. It can be used both as an initial screen for adolescent depression and to identify caregivers at risk for depression.
Next Steps for Pediatrics
In addition to moving upstream to prevent adverse experience and improve society-wide conditions for families raising young child, pediatrics should consider multigenerational, family-centered approaches for preventing and treating mental health problems in young children. These strategies range from providing information and support to address problematic child behavior, to initiating therapeutic interventions to attend to significant caregiver mental health or substance abuse problems, end domestic violence, or help families to cope with the burdens of persistent poverty and systemic racism. Sometimes the best intervention strategy for young children with serious behavioral or emotional problems is to focus directly on the primary needs of those who care for them. However, most approaches to funding mental health services are client-specific, rather than family-focused. And, most programs aimed at “adult” problems, such as poverty, domestic violence, substance abuse, or depression, do not take into consideration the emotional well-being of the children affected by them. More flexible approaches to funding family-based preventive and therapeutic mental health services are needed.
Pediatric healthcare providers would be better equipped to understand and manage the behavioral problems of young children if we had more intensive professional training focused on this area and easier access to child mental health professionals when needed. Pediatric training often includes little information regarding an up-to-date understanding of child mental health. The availability of a rich, scientific research base provides an opportunity to improve relevant curriculum and training programs.