Advances and Directions in Preschool Mental Health Research

World Psychiatric Association-Asian Journal of Psychiatry Commission on Public Mental Health

Although there is considerable evidence showing that the prevention of mental illnesses and adverse outcomes and mental health promotion can help people lead better and more functional lives, public mental health remains overlooked in the broader contexts of psychiatry and public health. Likewise, in undergraduate and postgraduate medical curricula, prevention and mental health promotion have often been ignored. However, there has been a recent increase in interest in public mental health, including an emphasis on the prevention of psychiatric disorders and improving individual and community wellbeing to support life trajectories, from childhood through to adulthood and into older age. These lifespan approaches have significant potential to reduce the onset of mental illnesses and the related burdens for the individual and communities, as well as mitigating social, economic, and political costs. Informed by principles of social justice and respect for human rights, this may be especially important for addressing salient problems in communities with distinct vulnerabilities, where prominent disadvantages and barriers for care delivery exist. Therefore, this Commission aims to address these topics, providing a narrative overview of relevant literature and suggesting ways forward. Additionally, proposals for improving mental health and preventing mental illnesses and adverse outcomes are presented, particularly amongst at-risk populations.

Social-emotional problems in 3-to 5-year-old children: a cross-sectional study of highly educated migrants in a Chinese urban area

Background

Previous research has primarily examined the mental well-being of children from labor migrant families, yet there is a lack of understanding regarding the mental well-being of children from highly educated migrant backgrounds. This study investigated the social-emotional problems of 3-5-year-olds from highly educated migrant families residing in an urban area of China, as well as explored potential differences in demographic variables.

Methods

A cross-sectional study was conducted in Qiantang District, Hangzhou, China, with 1,494 (53.3% boys) children selected via a convenient sampling method. The Ages & Stages Questionnaires: social-Emotional, Second Edition (ASQ:SE-2) was used to measure social-emotional problems.

Results

The results showed that 23.6% of the children were at risk for social-emotional problems. More boys (26.7%) than girls (20.1%) had scores above the cut-off. Additionally, more children in the low socioeconomic status (29.9%) had scores above the cut-off than those in the high socioeconomic status (18.9%). There were three common issues among all age groups: "being more active than others," "excessive attachment to parents," and "being overly friendly with strangers.

Conclusion

The social-emotional development of children from highly educated migrant families is a significant aspect that deserves recognition, contributing valuable insights to the existing literature on this topic.

Parenting style and child mental health at preschool age: evidence from rural China

BACKGROUND

Mental health problems among children at preschool age are a common issue across the world. As shown in literature, a caregiver's parenting style can play a critical role in child development. This study aims to examine the associations between a caregiver's parenting style and the mental health problems (or not) of their child when he/she is at preschool age in rural China.

METHODS

Participants were children, aged 49 to 65 months, and their primary caregivers. The primary caregivers of the sample children completed the Parenting Styles and Dimensions Questionnaire, Short Version, the Strengths and Difficulties Questionnaire, and a questionnaire that elicited their socio-demographic characteristics. The level of cognitive development of each sample child was assessed using the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition. Pearson correlation analysis, linear regression analysis, and multivariable regression analysis were used to analyze the data.

RESULTS

The prevalence of mental health problems among sample children at preschool age was high (31.6%). If a caregiver practices an authoritative parenting style, it was found to be negatively associated with the mental health problems of their child. In contrast, a caregiver's authoritarian parenting style was positively associated with the mental health problems of their child. Compared to those in a subgroup of primary caregivers that used a combination of low authoritative and low authoritarian parenting style, primary caregivers that used a combination of high authoritarian and low authoritative or a combination of high authoritative and high authoritarian were found to have positive association with child health problems. A number of demographic characteristics were found to be associated with the adoption of different parenting styles.

CONCLUSION

Different parenting styles (including authoritative, authoritarian, and combination of authoritative and authoritarian) of the sample caregivers had different associations with the mental health problems of the sample children. Parenting programs that aim to improve the parenting styles (favoring authoritative parenting styles) should be promoted in an effort to improve the status of child mental health in rural China.

Preschool-level socio-economic deprivation in relation to emotional and behavioural problems among preschool children in Sweden

AIMS

The aim of this study was to explore the association between preschool-level socio-economic deprivation and emotional and behavioural problems among preschool children in Sweden using a multilevel approach.

METHODS

In this cross-sectional study, we used data on 2267 children whose parents and preschool teachers had responded to items measuring individual-level socio-economic deprivation and the Strengths and Difficulties Questionnaire (SDQ) for assessment of emotional and behavioural problems. Further, the Socioeconomic Structure Compensation Index (SSCI), collected from Uppsala municipality, was used to assess preschool-level socio-economic deprivation. Unadjusted and adjusted multilevel logistic regression models were used to explore the relations between preschool-level socio-economic deprivation and emotional and behavioural problems.

RESULTS

In unadjusted models, children who attended preschools classified as highly deprived had elevated odds for emotional symptoms (odds ratio (OR) 1.71) as rated by parents. However, this association did not remain significant after adjusting for individual-level socio-economic deprivation factors. In both unadjusted and adjusted models, children who attended preschools classified as moderately deprived had elevated odds for peer-relationship problems as rated by parents (OR 1.63; adjusted OR 1.48). There were no significant associations between preschool deprivation and emotional and behavioural problems as rated by preschool teachers.

CONCLUSIONS

Swedish preschools may have a compensatory capacity in addressing children's emotional and behavioural problems, whereas preschool-level deprivation remained significantly associated with peer-relationship problems after controlling for individual-level socio-economic deprivation factors. This implies that peer-relationship problems in deprived preschools need to be addressed in a broader community context.

Addressing Early Education and Child Care Expulsion

An important goal of early childhood education is teaching emotional self-regulation within the context of a safe, stable, nurturing environment. Expulsion of young children ignores underlying emotional and behavioral concerns, disproportionately affects children of color (Black or Hispanic), males, children with disabilities, and socioeconomically disadvantaged populations, and has long-term consequences on educational and life success. Addressing implicit bias and providing child mental health consultation (psychologists, social workers, developmental behavioral pediatricians, child psychiatrists, and child neurologists) to child care providers can prevent expulsion. Pediatricians and other providers within the medical home play an important part in preventing expulsion. However, pediatricians need more training in early childhood mental health and in understanding how systemic racism and implicit bias lead to preschool expulsion in children of color. By identifying children at risk for expulsion because of poverty, racial discrimination, toxic stress, insecure attachment, or history of trauma, the pediatrician can connect families with community resources that may ameliorate these effects. Pediatricians can provide information on social-emotional development in early childhood, promote positive parent-child relationships, and model and discuss age-appropriate and developmentally appropriate behavior management. Pediatricians can also guide parents toward high-quality child care programs that use mental health consultation and developmentally appropriate activities, both of which lessen the chance of child expulsion. Furthermore, behavioral health providers integrated into the medical home can provide consultation to child care providers on managing patients. These recommendations are consistent with our knowledge of early child brain development and support the current tenets of the American Academy of Pediatrics regarding the pediatrician's role in building resilience and buffering toxic stress to promote optimal child development.

What is typical: Atypical in young children's attention regulation?: Characterizing the developmental spectrum with the Multidimensional Assessment Profiles-Attention Regulation Infant-Toddler (MAPS-AR-IT) Scale

While attention dysregulation is a promising early indicator of neurodevelopmental risk, in particular attention-deficit/hyperactivity disorder (ADHD), it is difficult to characterize clinical concern due to its developmental expectability at the transition to toddlerhood. Thus, explicating the typical:atypical continuum of risk indicators is among the key future directions for research to promote early identification and intervention, and prevent decrements in the attainment of developmental milestones into early childhood. In this paper, we present the Multidimensional Assessment Profiles-Attention Regulation Infant-Toddler (MAPS-AR-IT) Scale, a novel parent-report survey of dimensional, developmentally specified indicators of attention (dys)regulation. Item Response Theory was employed to characterize the typical:atypical spectrum of both normative and more concerning dysregulation (including the contexts in which behavior occurs). We provide evidence of the validity of this measure in capturing the full typical:atypical spectrum via a longitudinal sample of typically developing children at 12-18 months of age (baseline) via concurrent scores on well-validated temperament and clinical measures. We also examine longitudinal stability and predictive validity if the MAPS-AR-IT via a clinical interview of ADHD symptoms at 24-30 months (follow-up). While not diagnostic, we present evidence of the utility of the MAPS-AR-IT in explicating individual neurodevelopmental risk and elucidating the broader typicality of behaviors related to attention (dys)regulation.

Do general and specific factors of preschool psychopathology predict preadolescent outcomes? A transdiagnostic hierarchical approach

BACKGROUND

Preschool psychiatric symptoms significantly increase the risk for long-term negative outcomes. Transdiagnostic hierarchical approaches that capture general ('p') and specific psychopathology dimensions are promising for understanding risk and predicting outcomes, but their predictive utility in young children is not well established. We delineated a hierarchical structure of preschool psychopathology dimensions and tested their ability to predict psychiatric disorders and functional impairment in preadolescence.

METHODS

Data for 1253 preschool children (mean age = 4.17, s.d. = 0.81) were drawn from three longitudinal studies using a similar methodology (one community sample, two psychopathology-enriched samples) and followed up into preadolescence, yielding a large and diverse sample. Exploratory factor models derived a hierarchical structure of general and specific factors using symptoms from the Preschool Age Psychiatric Assessment interview. Longitudinal analyses examined the prospective associations of preschool p and specific factors with preadolescent psychiatric disorders and functional impairment.

RESULTS

A hierarchical dimensional structure with a p factor at the top and up to six specific factors (distress, fear, separation anxiety, social anxiety, inattention-hyperactivity, oppositionality) emerged at preschool age. The p factor predicted all preadolescent disorders (ΔR2 = 0.04-0.15) and functional impairment (ΔR2 = 0.01-0.07) to a significantly greater extent than preschool psychiatric diagnoses and functioning. Specific dimensions provided additional predictive power for the majority of preadolescent outcomes (disorders: ΔR2 = 0.06-0.15; functional impairment: ΔR2 = 0.05-0.12).

CONCLUSIONS

Both general and specific dimensions of preschool psychopathology are useful for predicting clinical and functional outcomes almost a decade later. These findings highlight the value of transdiagnostic dimensions for predicting prognosis and as potential targets for early intervention and prevention.

An Ounce of Prevention: Building resilience and targeting anxiety in young children

BACKGROUND

Anxiety disorders are among the most common psychiatric disorders in childhood and can develop as early as the preschool years. Therefore, providing young children who display early signs of anxiety with skills to prevent the development of later psychopathology is invaluable. The current study evaluates the effectiveness of Fun FRIENDS, an anxiety prevention and resilience program for young children.

METHOD

Fifty-seven kindergartners across three classrooms participated in a 15-week anxiety prevention program and teachers completed a behavioral screening measure and anxiety questionnaire at pre, post, 3 month, and 10-month follow-up assessment points.

RESULTS

Anxiety positively correlated with emotional symptoms, peer difficulties, and total difficulties at pre-intervention. Anxiety symptoms decreased from pre-intervention to follow-up. Additionally, prosocial behaviors improved and moderated the relationship between pre-and post-intervention anxiety symptoms.

CONCLUSIONS

These findings yield promising implications regarding the effectiveness of prevention and intervention programs on increasing social emotional skills and reducing anxiety symptoms in young children.

Pediatric clinicians' perspectives on assessing concerns about young children's social-emotional wellbeing in primary care

We surveyed pediatric primary care clinicians working in Federally Qualified Health Centers about their perceptions of children's social-emotional wellbeing. We identified clinician's current methods for assessing social-emotional wellbeing in practices, perceived implementation barriers to providing behavioral health care, and interest in adopting a validated, low-burden developmentally sensitive parent-report instrument for screening for social-emotional wellbeing in young children. We surveyed 72 PCCs working in FQHCs from 9 US states. Analyses included examining central tendencies, correlations, analysis of variance, and group differences via t-tests. Average PCC perceptions of social-emotional wellbeing importance for overall health were statistically significantly higher than their confidence in providing care for common social-emotional wellbeing concerns (mean difference = 1.31, 95% CI = 1.13-1.49). PCCs expressed low satisfaction with currently available screening measures for identifying concerns in social-emotional wellbeing. Fewer than half of clinicians reported using any standardized parent-reported measure for identifying concerns in social-emotional wellbeing. Assessment methods and decision tools that improve clinician confidence concerning risk indications are needed, particularly at the critical early childhood period. Policymakers and payers ought to facilitate funding mechanisms that support pediatric PCCs in identifying early concerns in social-emotional wellbeing and providing referral guidance to evidence-based interventions to support parents and caregivers.

Psychometric properties of the caregiver-teacher report form in a sample of Norwegian preschool children

PURPOSE

The caregiver-teacher report form (C-TRF) is included in the Achenbach system of empirically based assessment (ASEBA) and widely used to measure child psychopathology. In Norway, the C-TRF is frequently used by the Educational and Psychological Counselling Service or for referrals to special health services, however, its psychometric properties in the Norwegian context have not yet been explored. The aim of this study was to investigate the internal consistency of the C-TRF and its factorial validity in a Norwegian preschool context.

METHOD

This study is based on baseline data from the project Children in Central Norway, where a total of 169 preschool teachers reported on the C-TRF for 1430 children aged 1-6 years.

RESULTS

The findings indicate promising psychometric properties for the C-TRF in terms of internal consistency and factorial validity, however, the somatic complaints scale seems problematic because of its poor psychometric properties.

CONCLUSION

Users of the C-TRF can be confident in the instrument's applicability in a Norwegian context, however, careful considerations when applying the somatic complaints scale in clinical decision making is warranted.

Joint Consideration of Inhibitory Control and Irritability in Young Children: Contributions to Emergent Psychopathology

Deficits in self-regulation capacity have been linked to subsequent impairment and clinical symptomology across the lifespan. Prior work has identified difficulty regulating angry emotions (i.e., irritability) as a powerful transdiagnostic indicator of current and future clinical concerns. Less is known regarding how irritability intersects with cognitive features of self-regulation, in particular inhibitory control, despite its mental health relevance. A promising avenue for improving specificity of clinical predictions in early childhood is multi-method, joint consideration of irritability and inhibitory control capacities. To advance early identification of impairment and psychopathology risk, we contrast group- and variable-based models of neurodevelopmental vulnerability at the interface of irritability and inhibitory control in contexts of varied motivational and emotional salience. This work was conducted in a longitudinal study of children recruited at well-child visits in Midwestern pediatric clinics at preschool age (N = 223, age range = 3-7 years). Group-based models (clustering and regression of clusters on clinical outcomes) indicated significant heterogeneity of self-regulation capacity in this sample. Meanwhile, variable-based models (continuous multiple regression) evidenced associations with concurrent clinical presentation, future symptoms, and impairment across the broad spectrum of psychopathology. Irritability transdiagnostically indicated internalizing and externalizing problems, concurrently and longitudinally. In contrast, inhibitory control was uniquely associated with attention-deficit/hyperactivity symptoms. We present these findings to advance a joint consideration approach to two promising indicators of neurodevelopmental vulnerability and mental health risk. Models suggest that both emotional and cognitive self-regulation capacities can address challenges in characterizing the developmental unfolding of psychopathology from preschool to early childhood age.

Negative emotionality as a candidate mediating mechanism linking prenatal maternal mood problems and offspring internalizing behaviour

Negative emotionality (NE) was evaluated as a candidate mechanism linking prenatal maternal affective symptoms and offspring internalizing problems during the preschool/early school age period. The participants were 335 mother-infant dyads from the Maternal Adversity, Vulnerability and Neurodevelopment project. A Confirmatory Bifactor Analysis (CFA) based on self-report measures of prenatal depression and pregnancy-specific anxiety generated a general factor representing overlapping symptoms of prenatal maternal psychopathology and four distinct symptom factors representing pregnancy-specific anxiety, negative affect, anhedonia and somatization. NE was rated by the mother at 18 and 36 months. CFA based on measures of father, mother, child-rated measures and a semistructured interview generated a general internalizing factor representing overlapping symptoms of child internalizing psychopathology accounting for the unique contribution of each informant. Path analyses revealed significant relationships among the general maternal affective psychopathology, the pregnancy- specific anxiety, and the child internalizing factors. Child NE mediated only the relationship between pregnancy-specific anxiety and the child internalizing factors. We highlighted the conditions in which prenatal maternal affective symptoms predicts child internalizing problems emerging early in development, including consideration of different mechanistic pathways for different maternal prenatal symptom presentations and child temperament.

Temperament in Infancy Predicts Internalizing and Externalizing Problem Behavior at Age 5 in Children With an Increased Likelihood of Autism Spectrum Disorder

Differences in temperament have been linked to later mental health. Children with autism spectrum disorder (ASD) have an increased likelihood of experiencing such problems, including anxiety, depression, attention deficit/hyperactivity disorder, and oppositional defiant disorder; yet, relations between early temperament and later mental health are not well understood. In this paper, we assess the relationship between temperament in infancy and internalizing and externalizing behavior at age 5, in 178 children at an increased likelihood of being diagnosed with ASD (i.e., younger siblings of children with ASD). Temperament was assessed using the parent-reported Infant Behavior Questionnaire (IBQ) at 6 and 12 months of age and the Toddler Behavior Assessment Questionnaire-Revised (TBAQ-R) at 24 months of age. Mental health problems were assessed using the parent-reported Child Behavior Checklist (CBCL) at age 5. The data were analyzed using hierarchical multiple regressions, with individual temperament subscale scores as single predictor variables (Subscale Score) or temperament profiles using confirmatory factor analyses (Person-Centered Profile) in the first block, Autism Diagnostic Observation Schedule total severity scores at age 3 in the second block, and expressive and receptive language scores (from Mullen Scales of Early Learning) at age 3 in the third block for each model. Three main findings were: (1) 4 of 6 IBQ subscales at both 6 and 12 months significantly predicted internalizing and externalizing problems at age 5; (2) 9 and 8 of 13 TBAQ-R subscales at 24 months significantly predicted internalizing and externalizing problems, respectively, at age 5; and (3) a "sticky attention" temperament profile significantly predicted internalizing problems, whereas a "low-focused" profile significantly predicted externalizing problems, both at age 5. The results of this study support the supposition that temperament is a trans-diagnostic risk factor for later mental health conditions. Exploring temperament profiles and trajectories may illuminate early avenues for prevention in siblings of children with ASD who are at an increased likelihood of experiencing mental health problems, regardless of ASD diagnostic status.

Affective Dynamics and Mean Levels of Preschool Irritability and Sadness: Predictors of Children's Psychological Functioning Two Years Later

Although irritability and sadness are cardinal symptoms of depression, they are also common in preschoolers. The daily experiences of these emotions are not well-understood during early childhood, yet may provide insight into identification of early depressive symptoms. The current longitudinal study examined daily mean levels and emotion dynamics of preschool-aged children's irritability and sadness and psychiatric outcomes in early school-age. Parents (n = 291) completed 14 consecutive daily diaries about their preschoolers' emotions. Two years later, parents (n = 164) completed a semi-structured clinical interview and questionnaires about their children's psychological functioning. Strong correlations between mean and dynamic measures (rs = 0.65-0.91) were identified. Preschoolers' mean daily levels and dynamics of irritability (variability, instability, inertia) and sadness (instability, inertia) predicted symptoms and impairment 2 years later. Sadness instability and inertia continued to predict difficulties after adjusting for mean daily sadness. Fine-grained daily measures of preschoolers' affect may be help identify children at-risk for psychological problems.

Association Between Measures Derived From Children's Primary Exfoliated Teeth and Psychopathology Symptoms: Results From a Community-Based Study

Mental disorders are among the most disabling health conditions globally. However, there remains a lack of valid, reliable, noninvasive, and inexpensive biomarkers to identify (at an early age) people who are at the greatest risk of experiencing a future mental health condition. Exfoliated primary teeth, when used in combination with established and emerging tools (e.g., family history, imaging, genetics, epigenetics), may provide important additional insights about vulnerability to mental illness. Teeth are especially promising because they develop in parallel with the brain and maintain a permanent record of environmental insults occurring during prenatal and perinatal development. Despite their potential, few empirical studies have investigated features of exfoliated teeth in relation to mental health. Here, we used micro-CT imaging to test the hypothesis that measures derived from exfoliated primary incisors associated with psychopathology symptoms in a community-based sample of children (n = 37). We found that enamel volume (β = −0.77, 95% CI, −1.35 to −0.18, P = 0.01) had large negative associations with internalizing symptoms, and enamel mineral density (β = 0.77, 95% CI, 0.18–1.35, P = 0.01) had large positive associations with internalizing behavioral symptoms, even after stringent control for multiple testing. Pulp volume (β = −0.50, 95% CI, −0.90 to −0.09, P = 0.02) had a moderately-large negative association with externalizing behavioral symptoms, though these associations did not survive multiple testing correction. These results support the ongoing investigation of teeth as potential novel biomarkers of mental health risk.

Getting in synch: Unpacking the role of parent-child synchrony in the development of internalizing and externalizing behaviors

While substantial research supports the role of parent-child interactions on the emergence of psychiatric symptoms, few studies have explored biological mechanisms for this association. The current study explored behavioral and neural parent-child synchronization during frustration and play as predictors of internalizing and externalizing behaviors across a span of 1.5 years. Parent-child dyads first came to the laboratory when the child was 4-5 years old and completed the Disruptive Behavior Diagnostic Observation Schedule: Biological Synchrony (DB-DOS: BioSync) task while functional near-infrared spectroscopy (fNIRS) data were recorded. Parents reported on their child's internalizing and externalizing behaviors using the Child Behavior Checklist (CBCL) four times over 1.5 years. Latent growth curve (LGC) modeling was conducted to assess neural and behavioral synchrony as predictors of internalizing and externalizing trajectories. Consistent with previous investigations in this age range, on average, internalizing and externalizing behaviors decreased over the four time points. Parent-child neural synchrony during a period of play predicted rate of change in internalizing but not externalizing behaviors such that higher parent-child neural synchrony was associated with a more rapid decrease in internalizing behaviors. Our results suggest that a parent-child dyad's ability to coordinate neural activation during positive interactions might serve as a protective mechanism in the context of internalizing behaviors.

Asthma and allergies correlate with mental health problems in preschool children

AIM

To explore the relations between asthma, allergies and mental health problems in preschool children, aged 3-5 years.

METHODS

In this cross-sectional Swedish study, we used data on 4649 children in Uppsala municipality whose parents and preschool teachers had responded to questions measuring asthma and allergies, and the Strengths and Difficulties Questionnaire (SDQ) for assessment of mental health problems. Logistic regression models were used to explore the relations between asthma and allergies and mental health problems.

RESULTS

Children with asthma (8.5%) had elevated odds of having emotional symptoms as rated by parents (OR: 1.34; 1.02-1.76) and teachers (OR: 1.44; 1.09-1.91). According to parents' ratings, these children also had elevated odds of showing mental health problems in general according to the SDQ total score (OR: 1.42; 1.05-1.94). Children with food allergies or intolerance (4.4%) only had elevated odds of having emotional symptoms (OR: 1.64; 1.16-2.33), as reported by parents. These results remained significant after adjustment for parental background factors.

CONCLUSION

Preschool children with asthma and food allergies or intolerance are at risk of having concurrent mental health problems. Mental health problems should be assessed in children with these disorders. Adequate support and/or referral to specialised services should be offered when needed.

Teacher Nominations of Preschool Children at Risk for Mental Health Problems: how False Is a False Positive Nomination and What Make Teachers Concerned?

Identification attempts in populations with a low prevalence of problems usually result in a considerable number of false positives. Thus, the aim of the current study was to investigate the false positive rate following nomination of developmental concerns by preschool teachers and the reasons for which teachers raise developmental concerns about children who display non-clinical levels of mental health problems.A total of 1430 children aged 1 to 6 years in Norwegian childcare centers were classified as true positive, false positive, true negative, or false negative by comparing preschool teachers’ nomination with their ratings on the Caregiver-Teacher Report Form, resulting in 127 (9%) false positives and 1142 (80%) true negatives.Compared to the true negative group, the false positive group received significantly higher scores on internalizing problems, externalizing problems than true negatives, conflict and significantly lower scores on closeness. Children’s internalizing and externalizing problems and age were the main factors that increased the likelihood of teachers raising concerns, while increased closeness in the teacher-child relationship reduced the likelihood of being nominated. Children’s gender and conflict level were not significant when adjusting for other factors.These findings suggest that preschool teachers’ concerns about children’s development should not be discarded as the false positive group did show elevated levels of problem behavior and poorer teacher-child relationship compared to the true negative group. Scrutinizing concerns in collaboration with parents and other mental health professionals may be beneficial to ensure healthy development for children with elevated problem levels.

Pathways to social-emotional functioning in the preschool period: The role of child temperament and maternal anxiety in boys and girls

Individual differences in social-emotional functioning emerge early and have long-term implications for developmental adaptation and competency. Research is needed that specifies multiple early risk factors and outcomes simultaneously to demonstrate specificity. Using multigroup longitudinal path analysis in a sample of typically developing children (N = 541), we examined child temperament dimensions (surgency, negative affectivity, and regulation/effortful control) and maternal anxiety in infancy and age 2 as predictors of child externalizing, internalizing, dysregulation, and competence behaviors at age 3. Four primary patterns emerged. First, there was stability in temperament dimensions and maternal anxiety from infancy to age 3. Second, negative affectivity was implicated in internalizing problems and surgency in externalizing problems. Third, effortful control at age 2 was a potent mediator of maternal anxiety in infancy on age 3 outcomes. Fourth, there was suggestive evidence for transactional effects between maternal anxiety and child effortful control. Most pathways operated similarly for boys and girls, with some differences, particularly for surgency. These findings expand our understanding of the roles of specific temperamental domains and postnatal maternal anxiety in a range of social-emotional outcomes in the preschool period, and have implications for efforts to enhance the development of young children's social-emotional functioning and reduce risk for later psychopathology.

L’attachement et la mentalisation en pédopsychiatrie : une fenêtre sur le fonctionnement des enfants et de leurs parents

Le travail auprès de la clientèle en pédopsychiatrie et les défis qu’il pose amènent à revoir les pratiques cliniques afin de prendre en compte de façon systématique les notions d’attachement et de mentalisation chez les enfants et leurs parents. L’article traite d’abord des concepts d’attachement et de mentalisation et fait un résumé de l’état des connaissances sur ces derniers. Il est ensuite question d’un projet de recherche développé en pédopsychiatrie à la clinique spécialisée 0-5 ans de l’Hôpital en santé mentale Albert-Prévost (HSMAP). Nous présentons les résultats préliminaires de cette recherche de même que les défis rencontrés dans l’implantation du projet. Enfin, nous développons sur la façon d’aborder le travail clinique en considérant de manière systématique l’attachement et la mentalisation dans l’évaluation et l’intervention auprès des familles référées en pédopsychiatrie.

Principles for Guiding the Selection of Early Childhood Neurodevelopmental Risk and Resilience Measures: HEALthy Brain and Child Development Study as an Exemplar

The vast individual differences in the developmental origins of risk and resilience pathways combined with sophisticated capabilities of big data science increasingly point to the imperative of large, neurodevelopmental consortia to capture population heterogeneity and key variations in developmental trajectories. At the same time, such large-scale population-based designs involving multiple independent sites also must weigh competing demands. For example, the need for efficient, scalable assessment strategies must be balanced with the need for nuanced, developmentally sensitive phenotyping optimized for linkage to neural mechanisms and specification of common and distinct exposure pathways. Standardized epidemiologic batteries designed for this purpose such as PhenX (consensus measures for Phenotypes and eXposures) and the National Institutes of Health (NIH) Toolbox provide excellent "off the shelf" assessment tools that are well-validated and enable cross-study comparability. However, these standardized toolkits can also constrain ability to leverage advances in neurodevelopmental measurement over time, at times disproportionately advantaging established measures. In addition, individual consortia often expend exhaustive effort "reinventing the wheel," which is inefficient and fails to fully maximize potential synergies with other like initiatives. To address these issues, this paper lays forth an early childhood neurodevelopmental assessment strategy, guided by a set of principles synthesizing developmental and pragmatic considerations generated by the Neurodevelopmental Workgroup of the HEALthy Brain and Child Development (HBCD) Planning Consortium. These principles emphasize characterization of both risk- and resilience-promoting processes. Specific measurement recommendations to HBCD are provided to illustrate application. However, principles are intended as a guiding framework to transcend any particular initiative as a broad neurodevelopmentally informed, early childhood assessment strategy for large-scale consortia science.

Incorporating evidence-based behavioral teacher training into Head Start mental health consultation: Description and initial outcomes of a large-scale program

Development of a multicomponent mental health consultation program for a countywide Head Start program is described. The consultation program incorporates strategies from the evidence-based practice, Teacher-Child Interaction Training (TCIT). Through large group professional development trainings before the school year, comprehensive feedback reports based on observations, and in-class coaching via modeling and performance feedback on teachers' use of TCIT skills, the consultation program served 55 Head Start classrooms with 789 children. Outcome data are presented on teachers' improvement in TCIT skill use and the relative effectiveness of two coaching methods (i.e., modeling and performance feedback) used during consultation. Results from multilevel modeling analyses indicated that teachers improved in the use of multiple observed TCIT skills between the initial and midyear assessment (i.e., increased frequency of labeled praises, reflections, behavioral descriptions, and commands that were complied with; decreased frequency of commands that children did not have an opportunity to comply with). Additionally, teachers who received coaching in the form of performance feedback, in comparison to modeling, exhibited greater gains in the frequency of labeled praises and commands that resulted in compliance. Discussion focuses on implementation of evidence-based practice in large-scale preventative early interventions, study limitations, and directions for future research.

A Daily Diary Analysis of Preschool Depressive Behaviors: Prospective Associations and Moderators Across 14 Days

Depressive disorders can be observed in early childhood and are associated with significant concurrent and prospective impairment; however, little is known about day-to-day variations in common depressive behaviors in children. This study examined the day-to-day variability of two common depressive behaviors in preschool-aged children, sadness and irritability, and factors associated with the daily occurrence of these behaviors. Participants included 291 parents of preschool-aged children, and parents completed a 14-day daily diary. Results indicated that sleep quality did not prospectively predict next-day sadness or irritability the following day. We observed between-person stability, but within-person variability, in children's sadness and irritability across 14 days. We observed greater between-person stability and greater within-person variability in sadness and irritability for males and for children with fewer baseline psychiatric symptoms and lower baseline impairment. Findings provide a developmental perspective on normative patterns of sadness and irritability in young children and can inform prevention and individualized intervention efforts to reduce negative sequelae in at-risk preschoolers.

Social Skills in Children at Home and in Preschool

Preschool age is a crucial period for social development. Social skills acquired during this period are the basis for future life's success. This study aimed to investigate the level of social skills in preschool children at home and in preschool and to examine the association between children's social skills and environmental and cultural backgrounds. A cross-sectional study using a multistage cluster sampling method was conducted on 546 children studying in the preschool centers of an urban area of Iran. Data were collected through demographic and social skill questionnaires from parents and teachers. Our findings showed that the social skills of girls were more than those of boys at home. Further, the majority of children had a moderate level of social skills from the parents' and teachers' perspectives. There was a modest parent-teacher agreement in most domains of social skills. Moreover, a statistically significant association was reported between children's social skill domains and the child's birth rank, father's age, father's job, teacher's age, teacher's education, teacher's experience, and preschool classroom in terms of the numbers of children and the type of classroom. Accordingly, the risk of problems with social skills was reported to be relatively low. Therefore, more attention should be given to the family status and the teacher's and preschool center's characteristics to improve social skills in children.

Future Directions for Early Childhood Prevention of Mental Disorders: A Road Map to Mental Health, Earlier

Mental disorders are the predominant chronic diseases of youth, with substantial life span morbidity and mortality. A wealth of evidence demonstrates that the neurodevelopmental roots of common mental health problems are present in early childhood. Unfortunately, this has not been translated to systematic strategies for improving population-level mental health at this most malleable neurodevelopmental period. We lay out a translational Mental Health, Earlier road map as a key future direction for prevention of mental disorder. This paradigm shift aims to reduce population attributable risk of mental disorder emanating from early life, by preventing, attenuating, or delaying onset/course of chronic psychopathology via the promotion of self-regulation in early childhood within large-scale health care delivery systems. The Earlier Pillar rests on a "science of when to worry" that (a) optimizes clinical assessment methods for characterizing probabilistic clinical risk beginning in infancy via deliberate incorporation of neurodevelopmental heterogeneity, and (b) universal primary-care-based screening targeting patterns of dysregulated irritability as a robust transdiagnostic marker of vulnerability to life span mental health problems. The core of the Healthier Pillar is provision of low-intensity selective intervention promoting self-regulation for young children with developmentally atypical patterns of irritability within an implementation science framework in pediatric primary care to ensure highest population impact and sustainability. These Mental Health, Earlier strategies hold much promise for transforming clinical outlooks and ensuring young children's mental health and well-being in a manner that reverberates throughout the life span.

A needs-based workforce model to deliver tertiary-level community mental health care for distressed infants, children, and adolescents in South Australia: a mixed-methods study

BACKGROUND

High-quality mental health services for infants, children, adolescents, and their families can improve outcomes for children exposed to early trauma. We sought to estimate the workforce needed to deliver tertiary-level community mental health care to all infants, children, adolescents, and their families in need using a generalisable model, applied to South Australia (SA).

METHODS

Workforce estimates were determined using a workforce planning model. Clinical need was established using data from the Longitudinal Study of Australian Children and the Young Minds Matter survey. Care requirements were derived by workshopping clinical pathways with multiprofessional panels, testing derived estimates through an online survey of clinicians.

FINDINGS

Prevalence of tertiary-level need, defined by severity and exposure to childhood adversities, was estimated at 5-8% across infancy and childhood, and 16% in mid-adolescence. The derived care pathway entailed reception, triage, and follow-up (mean 3 h per patient), core clinical management (mean 27 h per patient per year), psychiatric oversight (mean 4 h per patient per year), specialised clinical role (mean 12 h per patient per year), and socioeconomic support (mean 12 h per patient per year). The modelled clinical full-time equivalent was 947 people and budget was AU$126 million, more than five times the current service level.

INTERPRETATION

Our novel needs-based workforce model produced actionable estimates of the community workforce needed to address tertiary-level mental health needs in infants, children, adolescents, and their families in SA. A considerable expansion in the skilled workforce is needed to support young people facing current distress and associated family-based adversities. Because mental illness is implicated in so many burgeoning social ills, addressing this shortfall could have wide-ranging benefits.

FUNDING

National Health and Medical Research Council (Australia), Department of Health SA.

Parasympathetic Regulation and Inhibitory Control Predict the Development of Externalizing Problems in Early Childhood

The current report examined the longitudinal relations between cognitive self-regulation, physiological self-regulation, and externalizing problems. At age 4 (n = 98; 49 girls) and 6 (n = 87; 42 girls), children completed the Day-Night task, which taps the inhibitory control dimension of executive function. During the task, cardiac activity was measured and respiratory sinus arrhythmia (RSA) was derived as an index of parasympathetic activity. Mothers reported on externalizing problems. A cross-lagged path model was used to estimate longitudinal predictions while controlling for stability in all constructs over time. Earlier inhibitory control negatively predicted later externalizing problems, but not vice versa. However, RSA reactivity moderated this link; better inhibitory control predicted fewer externalizing problems only when reactivity to the Day-Night task ranged from mild RSA suppression to RSA augmentation. Externalizing problems at 6 years were highest among preschoolers who augmented RSA but showed poor inhibitory control performance, suggesting that risk for psychopathology may be better delineated by viewing self-regulation from an integrated, multi-system perspective.

Screening for mental health problems in a Norwegian preschool population. A validation of the ages and stages questionnaire: Social-emotional (ASQ:SE)

BACKGROUND

Early detection of mental health problems in childhood is important. However, studies on screening instruments for preschool children are rare. The aim of this study was to validate the Ages and Stages Questionnaire: Social-Emotional (ASQ:SE) with teacher reports and examine its screening accuracy in a preschool population.

METHODS

A total of 1428 children, aged 18 months - 5 years, attending child-care centers were recruited in Norway. Their teachers completed a survey including the ASQ:SE and the Caregiver-Teacher Report Form (C-TRF). The Spearman's correlation was calculated for the convergence between the ASQ:SE and the C-TRF and the screening accuracy of the ASQ:SE was assessed using receiver operating characteristic (ROC) analysis with the criterion of a score at or above the 90th percentile for the C-TRF total problem score.

RESULTS

The Spearman's correlation between the total scores for the ASQ:SE and the C-TRF were from .49 to .72. The ROC analyses demonstrated that the ASQ:SE had a promising ability to classify children at risk based on the C-TRF criterion with AUC ranging from .87 to .96 for the different forms. The ASQ:SE generally demonstrated high specificity across all forms and some forms (from age 30 months upwards) produced both high sensitivity and high specificity using the selected cutoff values.

CONCLUSIONS

The ASQ:SE could serve as a good starting point for screening for social-emotional problems among children in child-care centers. The 30- to 60-month ASQ:SE forms exhibit promising psychometric properties and may prove useful for early detection. The 18- to 24-month ASQ:SE forms demonstrate more limited efficacy in detecting children at risk.

The Role of Language Skill in Child Psychopathology: Implications for Intervention in the Early Years

In this narrative review, we suggest that children's language skill should be targeted in clinical interventions for children with emotional and behavioral difficulties in the preschool years. We propose that language skill predicts childhood emotional and behavioral problems and this relationship may be mediated by children's self-regulation and emotion understanding skills. In the first sections, we review recent high-quality longitudinal studies which together demonstrate that that children's early language skill predicts: (1) emotional and behavioral problems, and this relationship is stronger than the reverse pattern; (2) self-regulation skill; this pattern may be stronger than the reverse pattern but moderated by child age. Findings also suggest that self-regulation skill mediates the relation between early language skill and children's emotional and behavioral problems. There is insufficient evidence regarding the mediating role of emotion understanding. In subsequent sections, we review evidence demonstrating that: (1) particular kinds of developmentally targeted parent-child conversations play a vital role in the development of language skill, and (2) some current clinical interventions, directly or indirectly, have a beneficial impact on children's vocabulary and narrative skills, but most approaches are ad hoc. Targeting language via parent-child conversation has the potential to improve the outcomes of current clinical interventions in the preschool years.

Depression and Anxiety in Preschoolers: A Review of the Past 7 Years

This article reviews recent empirical literature on the prevalence, correlates, assessment, and treatment of preschool-onset internalizing disorders. Major advances in the acceptance and recognition of both preschool-onset depression and anxiety have occurred over the past decade. This work has been greatly enhanced by the discovery of genetic, neural, and physiologic indicators, which further validate these constellations of symptoms in young children. Despite this growth in research, much work still needs to be done to further elucidate the cause, risk, treatment, and protective factors for preschool-onset internalizing disorders.

The interaction between parenting and children's cortisol reactivity at age 3 predicts increases in children's internalizing and externalizing symptoms at age 6

Little is known about the role of stress reactivity in the emergence of psychopathology across early childhood. In this longitudinal study, we tested the hypothesis that child cortisol reactivity at age 3 moderates associations between early parenting and children's internalizing and externalizing symptoms from age 3 to age 6. One hundred and sixty children were assessed at age 3, and 135 children were reassessed at age 6. At age 3, we exposed children to stress-inducing laboratory tasks, during which we obtained four salivary cortisol samples, and parental hostility was assessed using an observational parent-child interaction task. At ages 3 and 6, child psychiatric symptoms were assessed using a clinical interview with parents. The results indicated that the combination of high child cortisol reactivity and high observed parental hostility at age 3 was associated with greater concurrent externalizing symptoms at age 3 and predicted increases in internalizing and externalizing symptoms from age 3 to age 6. Findings highlight that increased stress reactivity, within the context of hostile parenting, plays a role in the emergence of psychopathology from preschool to school entry.

Suicidal thoughts and behaviors in psychiatrically referred young children

Despite increased awareness of the prevalence and seriousness of mental health problems in early childhood, there have been few empirical studies of suicidal thoughts and behaviors in this age group. This study examined suicidal thoughts and behaviors in 360 preschool-aged children (ages 3 to 7 years) presenting to a psychiatric day treatment program. A semi-structured diagnostic interview (conducted with primary caregivers) was used to assess for child suicidal thoughts and behaviors and psychiatric disorders. Participating mothers also reported on their own psychological distress and family psychiatric history. Forty-eight children (13%) were reported to have suicidal thoughts and behaviors, with suicidal plans or attempts endorsed for 2-3% of the sample. Suicidal thinking and behavior was associated with older child age and with higher rates of concurrent depression, oppositional defiant disorder, and posttraumatic stress disorder in univariate analyses, with age and depression remaining as significant predictors in a multivariate logistic regression model. Findings suggest that suicidal thoughts and behaviors are a significant clinical concern for young children presenting with early psychopathology, particularly depression, with implications for early childhood psychiatric assessment and treatment.

Latent class profiles of depressive symptoms from early to middle childhood: predictors, outcomes, and gender effects

BACKGROUND

There has been little available data to inform the predictors and outcomes of latent class trajectories of depressive symptoms beginning during preschool and continuing throughout school age. Further, the extant literature in this domain has been limited by the use of parent report checklists of nonspecific 'internalizing' psychopathology rather than diagnostic interviews for depression.

METHODS

To address these gaps in the literature, this study applied growth mixture modeling to depressive symptom severity endorsed by children and/or their caregivers (N = 348) during a structured clinical interview in a 10-year longitudinal dataset spanning from preschool into late school age.

RESULTS

Three distinct trajectories of depressive symptom severity were found in boys and girls. For boys, but not girls, the high depression severity latent class increased in depressive symptoms from preschool through school age, followed by a decline in depressive symptom severity during later school age. For girls, the high depression severity latent class remained stable across time. Early childhood social adversity, familial history of affective disorder, preschool-onset ODD/CD, and school age functional impairment differentiated high-risk trajectory classes among both boys and girls.

CONCLUSIONS

Extending the literature on trajectories of depressive symptoms to the preschool period, these findings incorporate structured clinical interviews of depressive symptom severity and indicate gender differences as well as psychosocial predictors and functional outcomes among children in high severity latent classes. The findings from this study suggest that increased attention to screening for depressive symptoms in early childhood is of significant public health importance.

Correlates and Consequences of Suicidal Cognitions and Behaviors in Children Ages 3 to 7 Years

OBJECTIVE

Despite research documenting the existence of depression and other psychiatric disorders in early childhood, little is known about the nature and consequences of suicidal cognitions and behaviors (SI) in young children ages 3 to 7 years. The identification of trajectories of SI across childhood is a critical step toward preventing childhood suicide.

METHOD

Participants were 306 children enrolled in a prospective longitudinal investigation of young children and their families. Children and their families completed a baseline assessment between ages 3 and 7 years, and at least 1 follow-up assessment (ages 7-12 years). Child psychopathology, suicidal thoughts, plans, and behaviors were assessed via parent and trained interviewer report before age 9, and also with self-report after age 9. Data on maternal history of psychopathology, as well as maternal and family history of suicide attempts, were also obtained through parent report.

RESULTS

Controlling for a range of clinical and demographic variables, early-childhood SI (as defined as suicidal thoughts, behavior, or any expression of plans/attempts occurring before age 7) and suicidal themes in play were concurrently associated with childhood attention-deficit/hyperactivity (ADHD) and oppositional defiant/conduct disorders (ODD/CD). Early-childhood SI also predicted school-age depression and ODD/CD; however, these findings were no longer significant after controlling for the same diagnoses at the childhood baseline. Longitudinal analysis indicated that early-childhood SI was a robust predictor of school-age SI, even after accounting for psychiatric disorders at both time points.

CONCLUSION

Extending current research, these findings demonstrate that early-childhood SI confers significant risk for continuation into school-age SI and is concurrently associated with ADHD and ODD/CD. Although the meaning of early-childhood SI remains unclear, results suggest that it is a clinically important phenomenon that should be carefully assessed and taken seriously as a marker of risk for ongoing suicidal ideation/behavior. These findings suggest that early screening for SI in childhood is indicated in clinical settings, particularly in children less than 7 years of age with depression and externalizing disorders.