Early Childhood Mental Health Promotion, Prevention and Treatment March 2018 Developmental Domains Physical Cognitive Social Emotional Need to spend more time with an intentional focus on social and emotional development. Predictor of early success in school General Developmental Considerations Children vary in the ages at which they achieve developmental capacities May be delayed and then catch up Various abilities can develop at a different rate May express the development of an ability differently in different contexts 1
Definition Social Development The ability to differentiate self from others The ability to attach initially to the primary caretakers The ability to have healthy relationships with others A complex set of skills that allow children to make friends, solve interpersonal conflicts and express and understand feelings in others. Definition Emotional Development Ability to identify and regulate emotions and behavior Capacity to identify feelings Empathy Management of strong emotions Delay gratification Control impulses Development of positive and healthy self-esteem Why Do We Need to Address The early experiences of infants and toddlers influence the physical architecture of their brain; These experiences determine the course of children s social-emotional development; Social-emotional development is the cornerstone of healthy development; Children entering school with well developed social and cognitive skills are most likely to succeed and least likely to need costly intervention services in later life. Sixty percent of children enter school with the cognitive skills they need to be successful, but only 40 percent have the social and emotional skills needed to succeed in kindergarten 2
Children are more likely to succeed in the transition to school if they can Accurately identify emotions in themselves and others; Relate to teachers and peers in positive ways; Manage feelings of anger, frustration and distress; Enjoy learning and approach it enthusiastically; Pay attention, and work both independently and cooperatively in a structured classroom environment Promoting Social and Emotional Health Relationships, Environments and Opportunities Brain Development Brain at Birth 25% the size of the adult brain in weight and volume (less than 1lb) Nearly the same number of neurons as adult brain (100 billion) 50 trillion synapses (connections between neurons) Brain stem and lower brain well developed (reflexes), higher regions more primitive 3
Social-emotional well-being is promoted when young children have: Safe and appropriate food and shelter; Attentive, consistent, responsive and affectionate care and interaction from parents and other primary caregivers; A nurturing relationship with at least one parent or a primary caregiver; Adult caregivers with social and emotional supports in place in their own lives; 4
Resilience Able to recover quickly from misfortune; A human ability to recover quickly from disruptive change, or misfortune without being overwhelmed or acting in dysfunctional or harmful ways. Key is a fit between the organizing and regulating systems of the mother and child Quality of Care Quality and Quantity of stimulation in environment Quality of Social Supports A balance between protective and risk factors Prenatal Researchers have found that a baby's emotional state begins developing well before the baby's birth Sounds and voices, as well as the mother's overall mood--whether she is happy or stressed or upset--can help mold the child's emotional state. The emotion or feeling of stress is evident in the baby if the mother is also under stress. A rise in the mother's blood pressure will trigger a response in the baby's blood pressure as well. Sets the stage for recognizing voices that aid in soothing after birth Birth/Infants Caregiver an extension of child s internal regulatory system Holding the baby Helps in regulation of heart rate, breathing, temperature and other physiological functions Begins the bonding/attachment process Infant emotions are evoked by physical conditions such as hunger, discomfort, temperature or fatigue; Young babies interactions are emotionally based Smiling Crying Imitation How caretakers respond to the infant s needs help define the infant s most basic view of the world 5
Attachment Attachment involves two components in the infant-caregiver relationship: the infant's need for protection and comfort, and; the caregiver's provision of timely and appropriate care in response to these needs Research suggests that a child s sense of safety and security is as important to emotional/social well-being as actual safety is to physical well-being. Child and caregivers personality and temperament impacts interaction A secure relationship with a caregiver provides the most important defense against overwhelming stress Attachment Secure: trusts that her parents are consistently available. When the child is frightened or unsure about something looks to caregiver for comfort (50-70%) Anxious-ambivalent: cannot count on parents to respond consistently. Sometimes the parent is nurturing and sometimes not. The child uses two coping strategies interchangeably clinginess and feigned independence to demonstrates insecurity. (10-20%) Avoidant: seeks little contact with their mothers and were not distressed when they left. (10-20%) Disorganized: Frightening, overwhelming caregiver behavior, child is afraid of caregiver and cannot predict response. No strategy for dealing with his parents failure to protect and nurture so may attempt to engage with unusual behaviors. Greatest risk for developing psychopathology (5%) Impact of Attachment Impacts the release of cortisol Children who had secure attachments at 1 y/o tend to be popular with peers, resilient, resourceful, and cooperative in preschool. By age 6, they are more compliant, responsive, self-reliant and empathic. Secure attachments appear to act as a protective factor against emotional and behavioral problems in childhood and adolescence. Those without secure attachments are more likely to provoke adults and peers into rejecting them and may victimize others; OR May be easily frustrated or passive and helpless, seeking disproportion adult attention 6
Building Positive Relationships Starts prenatally exposure in the womb Birth first lesson in self-regulation First 12 months provide a sense of safety and comfort via present, attuned and responsive caregiver Serve and Return Self-regulation via relationship 12 to 24 months Parallel Play Development of Empathy Praise motivation/attempts/process not just outcome Model effective problem solving and negotiation skills Be a safe home base to encourage appropriation exploration Environment A language-rich environment including opportunities for reading, singing, listening and talking; Play environments that offer toys and other play materials that encourage exploration and are developmentally appropriate for the young child; Encouragement and support for the development and mastery of new skills; Pre-School Age Preschoolers emotions are tied to their psychological condition how they interpret their experiences, what they think others are doing or thinking, and expectations about future events. Preschoolers are capable of anticipating and talking about their emotions and those of others, and can begin to use strategies to manage their feelings. Preschoolers can feel empathy for other people and experience more subtle blends of feelings than they did as infants and toddlers. 7
Strong, positive relationships Provide comfort, safety, confidence, and encouragement. Teach toddlers how to form friendships, communicate emotions, and to deal with challenges. Help children develop trust, empathy, compassion, and a sense of right and wrong. Children learn to regulate thoughts, feelings, behavior, and emotion by watching and responding to adults self-regulation In the earliest years most mental health disorders often result from problems in the child s primary attachment relationship. Building Positive Relationships 24 to 36 - empathy and peer interactions, conflict resolution Focus on feelings vocabulary, play, reading Model appropriate expression of feelings and guide them Encourage development of new relationships Give them opportunities to make decisions/choices Tips Be a model Teach intentionally not just when they have done something wrong Practice builds the brain connections that sustain positive behaviors Supportive Environments Safety Meets Needs Predictable/Consistent Engaging Appropriate Stimulation 8
Social and Emotional Teaching Strategies Building Healthy Relationships Knows how to engage others in play Sharing Problem/Conflict Resolution Taking Turns/Delayed Gratification Helping/Supporting Others (external focus) Positive Regard Responsibility and Apologies Social and Emotional Teaching Strategies Emotional Literacy Increase emotional vocabulary Recognition of Emotions in themselves and others Scenarios that help them relate to feelings Daily feeling identification Interactions between people s feelings Emotional Regulation Problem Solving Skills Connections between behavior and effects Mental Health Issues in Infants and Toddlers Identification and Interventions 9
DC: 0-5 Axis I (Clinical Disorders):Expanded from 30 to 42 disorders and more closely aligned with DSM-5 (APA, 2013). Axis II (Relational Context):Includes rating both the child-primary caregiving relationship adaptation and the caregiving environment. Axis III (Physical Health Conditions and Consideration):expanded list of examples of physical, medical and developmental conditions. Axis IV (Psychosocial Stressors):expanded list and reorganization of stressors for young children and their families. Axis V(Developmental Competence):expanded to capture a broad range of developmental competencies through the first five years Axis I Categories of Disorders Neurodevelopmental Disorders Sensory Processing Disorders Anxiety Disorders Mood Disorders Obsessive Compulsive and Related Disorders Sleep, Eating and Crying Disorders Trauma, Stress and Deprivation Disorders Relationship-Specific Disorder New Diagnosis in DC: 0-5 Relationship Specific Disorder of Early Childhood Disorder is evidenced between the child and a specific primary caregiver rather than within-the-child and expressed in most settings. Children construct different kinds of relationships with different caregivers based on their lived experiences with each caregiver. Relationship disorder diagnosis calls attention to what may be the most useful target of intervention Not intended to blame a parent or caregiver for ZERO TO shortcomings. THREE 10
Challenging Behaviors Behavior communicates a message particularly if the child doesn t yet have language Children typically exhibit challenging behaviors because it works to meet their needs Challenging behaviors typically relate to an interaction with others or ability to regulate emotions Often indicates problems in the social/ emotional development Challenging behavior must be considered within the context of the relationship of the child to caregivers Prevalence In a summary of the community surveys of young children, reported the following range of rates of childhood disorders: ADHD from 2% to 5.7%; ODD from 4% to 16.8%; Conduct Disorder from 0% to 4.6%; Depression from 0% to 2.1 %; Anxiety disorders from 0.3% up to 9.4%. Of those with one disorder, approximately 25% have a second disorder. The proportion of children with comorbidity increases about 1.6 times for each additional year from age 2 (18.2%) to 5 (49.7%). Logger et al., Dialogues Clin Neurosci. 2009 March; 11(1): 7 20. Risk Factors Heightened risk for children living in families coping with certain stressors, including: Parental loss Parental substance abuse Parental mental illness Exposure to adverse experiences Prenatal Exposure Low Birth Weight Biology Genetics Difficult Temperament/Predispositions 11
Trauma and Stress Adversely impact brain architecture - in the extreme a smaller brain Relationship with caregivers plays a critical role in regulating stress hormone production (study showed link between quality of childcare linked to stress hormone levels) Fear and stress managed through limbic system/amygdala, we interact and often intervene through cognitive portions of the brain Disrupts brain architecture and leads to stress management systems that respond at relatively lower thresholds, increasing the risk of physical and mental illness Ensure Social and Emotional Screening Part C First Steps Pediatrician ASQ-SE Parents Evaluation of Developmental Status (PEDS) Pediatric Symptom Checklist (PSC) DECA and DECA-C Assessing Children Reliability of Childhood Diagnoses Developmental Issues - Normal developmental behaviors are viewed as psychopathology such as calming difficulties, demanding adult company, inability to wait, overreacting to loud sounds or strong visual images, not wanting to have eyes covered, and sensitivity to temperature Lack of verbal abilities in child leading to presumptions about internal states Children are not little adults Manifestation of Symptoms in Children Pre-Morbid States in Childhood 12
ADHD Diagnosis Deciding if a child has ADHD is a several step process There is no single test to diagnose ADHD, Many other problems can have similar symptoms Medical exam including hearing and vision exam Checklist for rating ADHD symptoms History of the child from parents, teachers, and sometimes, the child. Differential Diagnoses Auditory processing disorder is a condition where something is adversely affecting the way someone processes or interprets the information that comes from the sounds around them. It involves difficulties with listening, or with recognizing differences in the sounds within words. Anxiety Disorders Individuals who have been traumatized (abuse, chronic neglect, natural disasters, accidents) may show many of the same features of ADHD Inattention Irritability Poor concentration Sleep Problem AD/HD and anxiety appear less responsive to conventional AD/HD medication treatments. Children with AD/HD and anxiety only showed a 30 percent response to methylphenidate (Ritalin), versus a 70-80 Behavioral Treatments Children with AD/HD face problems in daily life that go well beyond their symptoms of inattentiveness, hyperactivity and impulsivity poor academic performance behavior at school, poor relationships with peers and siblings, failure to obey adult requests, poor relationships with their parents These problems are extremely important because they predict how children with AD/HD will do in the long run. 13
Other Treatments Many psychotherapeutic treatments have not been proven to work for children with AD/HD. Traditional individual therapy, in which a child spends time with a therapist or school counselor talking about his or her problems or playing with dolls or toys, is not behavior modification. Talk" or "play" therapies do not teach skills and have not been shown to work for children with AD/HD Interventions can then be conceived as an attempt to shift the balance from vulnerability to resilience, to decrease exposure to risk factors and stressful life events and increase the number of protective factors (i.e., competencies and sources of support) in the lives of vulnerable children. Family Focused Interventions Child Parent Psychotherapy Attachment and Bio-behavioral Catch-Up Video Feedback to Promote Positive Parenting Triple P (Positive Parenting Practices), Incredible Years Series (IYS), Parent Child Interaction Therapy (PCIT) Ensure screening/assessment of parents mental health 14
Classroom Interventions Early Childhood Mental Health Consultation Teaching Tools for Young Children with Challenging Behaviors University of South Florida, Louis de la Parte Florida Mental Health Institute Early Childhood Positive Behavior Interventions and Supports Facilitating Individualized Interventions to Address Challenging Behavior, Center Treatment - Medication Significant increase in use of psychotropic medications in children in the 90 s and continues today Desire for quick fix and impact of consequences if don t medicate Minimal research on long-term impact of prescribing psychotropic medications on young children Not tested on children Differences in how children, adults and older adults metabolize meds Non-pharmaceutical interventions should ALWAYS be tried first or simultaneous with use of medications Thank you and Good Luck! 15