Even young children can experience mental health problems. Trauma or loss can be devastating to children's emotional well-being even in infancy, and a disorder such as ADHD needs to be addressed as early as possible. Questions answered in this Chat include, “Isn't a preschool child too young to have a serious mental health problem? Won't he or she just grow out of it?” “Do more young children have serious emotional problems today than 5 or 10 years ago?” “What approaches can parents and teachers of young children take to develop children's mental health in positive ways?”
Samantha Wulfsohn, Ph.D. is a licensed psychologist with a degree in Human Development and School Psychology from the University of Wisconsin-Madison. She has been working with children for over 15 years and has specialized in infant mental health and Autism spectrum disorders. Dr. Wulfsohn has experience providing mental health consultation to staff and families participating in Head Start and Early Head Start programs. Additionally, she has been a supervising psychologist for an intensive in-home program for children with Autism Spectrum Disorders. Currently, Dr. Wulfsohn directs an inclusion and mental health consultation project at Erikson Institute and provides Relationship Development Intervention and other services to children with Autism.
Within the last decade, the early childhood field has started to develop an interest in the mental health of young children. Researchers and advocates agree on the importance of young children's mental health to their overall development. In fact, children whose mental health needs are not met are at increased risk for significant impairment at home, with their peers, in school and in the community. This is especially relevant in light of the recent research on the importance of early brain development for later functioning. Moreover, evidence about how stress can negatively impact young children's development further demonstrates the importance of considering mental health in the early years.
Infant and early childhood mental health refers to children's healthy emotional development and social competence. This includes the way that children relate to others, how they feel about themselves, and how they manage emotions and impulses. The earliest experiences in life can set the stage for age-appropriate social-emotional development. Nurturing and positive relationship with parents or caregivers, safe and stable environments, and overall supportive emotional experiences are all important aspects of these early experiences. However, for some children these early experiences are problematic, resulting in social and emotional delays. Early warning signs of mental health concerns vary dramatically for children according to the child's temperament, environment, and age. For younger children, relationships with their caregivers and peers may be problematic. Additionally, some children may exhibit extreme aggression and emotional dysregulation, while others may be sad, withdrawn, or unengaged with others.
For these young and vulnerable children it is imperative that we address concerns as early as possible to prevent problems from becoming extreme. Services for young children with mental health concerns should adopt a prevention and family-centered focus with the goal of strengthening parent-child relationships and promoting children's social and emotional skills.
Guest [Samantha Wulfsohn]: I am so pleased to be here tonight and appreciate your interest in mental health issues. This is an exciting topic and I am looking forward to a lively conversation.
IEL moderator [Email-submitted Question]: Isn't a preschool child too young to have a serious mental health problem? Won't he or she just grow out of it? Sometimes I think that we are manufacturing conditions that don't exist.
Guest [Samantha Wulfsohn]: First, I want to recognize that the word "mental health" is a scary word which carries a lot of stigma, especially for our youngest children. Additionally, on rare occasions, young children are incorrectly diagnosed with a variety of mental health problems such as Attention Deficit Hyperactivity Disorder (ADHD) or Juvenile Bipolar Disorder.
However, it is extremely important not to dismiss the importance of children's healthy emotional development early in life especially in light of the research on brain development in the first three years. For these reasons much of the work around mental health concerns emphasizes prevention and early intervention with the goal of avoiding serious mental health problems later in life.
In spite of prevention and early intervention efforts, young children do experience extreme mental health problems. For instance, the effects of trauma or loss can be devastating to children's emotional well-being even in infancy. Moreover, a disorder such as ADHD can occur in young children and needs to be addressed as early as possible.
Participant [Nancy]: In my experience as a teacher, my impression has been that young boys exhibit mental and emotional health problems more often than girls do. Is there a gender difference?
Guest [Samantha Wulfsohn]: Nancy, boys often will demonstrate what we call externalizing behavior. This refers to things like aggression, hyperactivity, etc. For these reasons, boys often come to our attention. Girls are more likely to demonstrate what we call internalizing behavior, things like withdrawal, and so they get lost in the system sometimes. Also, keep in mind that girls will sometimes demonstrate "relational aggression." This can involve hurting other’s relationships by manipulating or eliciting peer rejection of others and can be quite problematic.
IEL moderator [Email-submitted Question]: I hear from many preschool teachers that more children are coming to their classrooms with serious emotional problems today than 5 years ago. Do more young children have serious emotional problems today than 5 or 10 years ago?
Guest [Samantha Wulfsohn]: There is certainly a greater awareness and value placed on children's emotional well-being. This suggests that increases in the number of children with emotional problems may be in part a result of us noticing something that already existed. However, over the past decade children have been experiencing a greater number of stresses that can contribute to emotional problems.
Children who experience multiple stresses are at a greater risk for experiencing emotional problems. These include the stress associated with poverty (1 in every 4 or 5 children is living in poverty today), violence in the home and community, parent mental health problems, single parents, parent incarceration, homelessness, etc.
IEL moderator [Email-submitted Question]: Low-quality child care, watching too much TV, poor parenting, and neighborhood violence have all been cited as root causes for emotional problems in children today. What do you see as the primary root causes for emotional problems in young children?
Guest [Samantha Wulfsohn]: The cause of emotional problems is complicated, because children are complicated. As we know from developmental research many factors contribute to a child's emotional problems including their own biological risk, problems in their relationships with others, and the stresses in their environment.
Poverty is one example of an extremely harmful risk factor to children's emotional development. Moreover, the more stresses a child experiences, the more likely the child's emotional well-being may be compromised. However, a child's predisposition and temperament can put them at risk for having mental health problems even when there are no environmental risk factors present. Moreover, a positive relationship with a caring adult or an easygoing temperament may provide a buffer to the negative effects of multiple environmental stresses.
Participant [maryjo]: Could you please distinguish between a young child's healthy sexual behavior and indicators of possible sexual abuse to the young child?
Guest [Samantha Wulfsohn]: It is normal for young children to engage in sexual exploration. Parents and teachers are sometimes concerned when they see young children looking at each other's private parts or masturbating. However, this behavior is normal.
When children engage in activity that seems adult-like, something that they had to learn from watching others for instance, then we should be concerned. Also children who engage in excessive masturbation and demonstrate sudden changes in their behavior or regression are concerning. Finally, when this behavior is accompanied by other aggression or withdrawal, teachers and parents should be concerned.
IEL moderator [Email-submitted Question]: What kinds of mental health problems are difficult to diagnose in young children?
Guest [Samantha Wulfsohn]: Generally, it is difficult to diagnose young children using the current system, the Diagnostic Classification System for Mental Health Disorders (DSM IV). For instance, Attention Deficit Hyperactivity Disorder (ADHD) can be difficult to diagnose in young children. Some of the features of ADHD are part of normal development, whereas some of the symptoms may be caused by stress or trauma.
However, there is a system that has been developed specifically for young children, the Diagnostic Classification System for 0 to Three. This taxonomy was developed for children from birth to six and considers concerns with the child, their relationship with primary caregivers, and other environmental stresses.
IEL moderator [Email-submitted Question]: What approaches can parents and teachers of young children take to develop children's mental health in positive ways?
Guest [Samantha Wulfsohn]: Early positive relationships provide the foundation for children's positive mental health. Children who experience consistent, nurturing, and responsive caregiving early in life will be more likely to have success later in life.
After this foundation is set, parents and teachers can foster positive mental health by encouraging children to understand their own emotions and the emotions of others. Moreover, children who learn how to regulate their behavior and feelings will develop positive mental health. This includes learning how to express negative feelings appropriately and how to calm down. Additionally, children who are able to get along with their peers and solve conflicts are more likely to be socially and emotionally well adjusted.
Two excellent books that provide more information on how to address preschooler's mental health needs and facilitate emotional development are Unsmiling Faces: How Preschools Can Heal, by Lesley Koplow (published by Teachers College Press in 1996) and The Emotional Development of Young Children: Building an Emotion-Centered Curriculum, by Marilou Hyson (published by Teachers College Press in 2003).
Guest [Samantha Wulfsohn]: The DC 0-3 was developed specifically because of concerns about diagnosing young children. It considers the importance of relationships for young children, problems with the child, stresses in the environment, and developmental issues. It is used formally in several states and Illinois is looking to adopt it. You can learn more about this system at the Zero to Three Web site.
IEL moderator [Email-submitted Question]: What are some promising practices or initiatives you are seeing around the state to address concerns about young children's mental health?
Guest [Samantha Wulfsohn]: There are many mental health initiatives in the state of Illinois. To access information on these initiatives, you can go to the Illinois Association for Infant Mental Health, the Ounce of Prevention Fund, and the Illinois Children's Mental Health Partnership (ICMHP).
With regard to the latter organization, see the ICMHP's "Draft PLAN Recommendations and Strategies for Building a Comprehensive Children's Mental Health System in Illinois."
[IEL Editor]: The Web sites of the organizations that Dr. Wulfsohn just mentioned are available at:
Participant [Nancy]: In my question related to gender, you mentioned girls with a mental health problem demonstrating internalizing behavior. Does that include shyness or should this be considered a normal personality trait?
Guest [Samantha Wulfsohn]: Nancy, shyness is a personality trait and is normal. Children who are extremely inhibited might be at risk for developing anxiety disorders later in life. Of course, the role of a child's environment, experiences, and relationships can all have an impact on this. Jerome Kagan is a researcher who has done a lot of work on temperament and inhibition, if you are interested in the science. He also has a readable book called Galen’s Prophecy: Temperament in Human Nature (published by Westview Press, reprint edition, 1995).
Participant [maryjo]: In my work as an early childhood mental health specialist, I often have to refer children for further evaluation. The difficulty comes with many parents not accepting that their child may need further mental evaluation. Do you have any suggestions on how to talk with the parents to get them to realize that early intervention is so important.
Guest [Samantha Wulfsohn]: maryjo, this can be very difficult as it is hard for families to accept problems of any kind in their child. Sometimes it is helpful to provide some developmental expectations that are realistic. Perhaps they can be invited to observe their child in the classroom. Also, with time as you build relationships with parents, they may come to trust your perspective. Finally, emphasizing the prevention piece, "We don't want this to grow into something extremely problematic," may help.
Participant [maryjo]: What would you suggest to a parent whose child age 6 with Asperger's Syndrome is in a public school that wants the child to attend for only 3 hours a day? The parent is frustrated with the current recommendation.
Guest [Samantha Wulfsohn]: maryjo, are there any reasons for why the school is limiting the child's time? Is it because of behavior and safety issues? I can imagine that this is frustrating for the family. It is always best to work collaboratively with the school if at all possible. It is hard for families not to become angry with schools, but they can get more if they are on the same side.
Participant [maryjo]: The parent seems to think that it's because the school does not want to take the extra effort needed for the child. The parent has had difficulty getting the school to follow the therapy schedules this year and is considering home schooling the child. However, the parent also very much sees that the child loves and needs the social learning with other children. That is why it is such a difficult decision.
Guest [Samantha Wulfsohn]: maryjo, one way to ensure the child is getting a fuller day is through the IEP process. If this is written into the IEP the school will need to make its best effort to meet this need. Also, ask for an autism consultant with the district. If they decide to home school, it may be important to try to access social groups or find some after school activities.
IEL moderator [Email-submitted Question]: What resources exist for parents and teachers of young children who have specific concerns about their children's mental health?
Guest [Samantha Wulfsohn]: There are some excellent resources on line focusing specifically on young children's mental health. Some examples of these are as follows.
Participant [KNS]: How are children affected that have siblings with emotional or behavior disorders?
Guest [Samantha Wulfsohn]: KNS, siblings can be affected in several ways. This of course can depend on what the disorder is. First, they may demand a lot of time from their parents, so the siblings' needs may become secondary. Because some disorders have a genetic risk, siblings may demonstrate some problems also.
Stress at home can contribute to children's problems with adjusting. So if a child has a sibling with extremely aggressive behavior, for instance, this can create stress for the child. Siblings, however, may be fine in spite of having a brother or sister with mental health issues and may learn from this.
Participant [maryjo]: Do you have any suggestions about what to provide to help children with sensory integration disorder, specifically mouthing objects and clothing excessively?
Guest [Samantha Wulfsohn]: maryjo, this is an area for the expertise of an OT (occupational therapist). However, I have seen that giving them something appropriate to chew on is a good option. For children who are old enough, chewing gum or having something chewy in their mouths can be helpful. Sometimes using a toothbrush with peanut butter or lemonade powder can be helpful.
Some great resources in this area are The Out of Sync Child and The Out of Sync Child Has Fun.
[IEL Editor]: Here's some more bibliographic information for these books:
IEL moderator [Email-submitted Question]: A young child in my child care program displays emotional extremes: he is very angry one day, very withdrawn the next, and very happy and bubbly another day. I would like to talk to this child's parents about my concerns, but I don't know how to start a conversation without alarming them. What suggestions do you have?
Guest [Samantha Wulfsohn]: It is always easier to talk to parents about a concern if you already have a positive relationship with them, one that is built on your shared goal of trying to help their child grow and develop. If you have talked to this child's parents about things that have been going well, it may be easier for them to hear about your concerns.
Also, I always consider parents as the "experts" on their child, so it will be helpful to ask them what they see at home. They may be worried but have not had a way to bring it up with anyone. Or they may provide you with information about changes that have been going on at home. You could start the conversation by describing what you see, asking them if they see the same things at home, and asking them if this is something that concerns them.
IEL moderator [Email-submitted Question]: I have heard that if children ingest lead or mercury, it can affect their mental health. Is there any way to tell if a child is being affected by environmental poisons? And what can be done to help such children?
Guest [Samantha Wulfsohn]: I am aware that lead poisoning can have a negative impact on children's development in many areas. With regard to the social emotional arena, children who have had high levels of lead in their system may demonstrate behavior problems including impulsivity, attention problems, and problems with peers. The only way to determine if a child has ingested lead is to test their blood levels.
Mercury has been implicated by some for the increased rise of Autism. Thimerosal, which is a mercury-based preservative used in the Mumps, Measles, Rubella vaccine, was blamed for causing Autism by many parents and some researchers. However, the Institute of Medicine of the National Academies conducted a thorough review of clinical and epidemiological studies. They showed that the measles-mumps-rubella (MMR) vaccine and Thimerosal, the mercury-based preservative used in vaccines, are NOT associated with autism.
Participant [maryjo]: How much do researchers know about the heredity possibility of children diagnosed with autism spectrum disorders?
Guest [Samantha Wulfsohn]: maryjo, researchers have started working on this question. Different projects have attempted to identify specific combinations of genes. However, there is no consistent finding yet. There is general agreement, however, that Autism is a brain-based disorder and has a genetic component.
Go to the National Institute for Health for updates on research in this area: NIH: Autism Spectrum Disorder
Participant [eileen]: Recently there have been articles and news items marking the striking increase in Autism/Asperger's Syndrome, especially it seems, in California. Do you have any thoughts on why this is? Better diagnosis or is it some environmental factor?
Guest [Samantha Wulfsohn]: Eileen, the increase in diagnosis has been related to an increased awareness in part. Also, the diagnosis catches more children because it has become more open. As a "spectrum" disorder it is capturing children with less extreme problems.
I have heard a statistic from California suggesting that the increase in diagnosis of Autism has been accompanied by a decrease in the diagnosis of "non-specified mental retardation."
Participant [maryjo]: Any specific resources that you are aware of to help teachers with children diagnosed or exhibiting characteristics of Asperger's Syndrome?
Guest [Samantha Wulfsohn]: There are many resources and I would start with the Web. Try the Autism Society of America, http://asa.org.
Also, the Family Village is a great resource: http://familyvillage.wisc.edu.
Some books are:
Participant [maryjo]: Your suggestions and resources have been very helpful to me this evening.
IEL moderator [Email-submitted Question]: When people talk about "professional help" for young children with mental health problems, what exactly do they mean? I have a hard time picturing a young child on a psychiatrist's couch!
Guest [Samantha Wulfsohn]: Working with the family is the most common and effective way to address mental health concerns in young children. This may include supporting positive relationships between children and their parents, helping parents to respond to and address behavioral concerns at home, helping them to learn to play with their child and providing them with support around parenting their child.
Additionally, addressing parents' own stresses and mental health needs is an important aspect of supporting young children's mental health. In some cases a therapist will use play to address mental health concerns with children in individual therapy.
IEL moderator [Email-submitted Question]: Are children born with a predisposition to develop mental health problems, or are these problems caused by children's environment and care?
Guest [Samantha Wulfsohn]: As I mentioned earlier, some children come into the world with biological risk factors. For instance, children whose parents have mental health problems may be at greater risk for developing mental health problems. Moreover, disorders like Autism and ADHD are likely to be brain-based disorders.
However, environmental risk factors can also contribute to mental health problems. The interaction of environment factors and biology can be extremely complicated. For example, different children may react to the same stresses in different ways. On the one hand, a child who is temperamentally inhibited or who is hypersensitive to change may demonstrate behavior problems in response to a violent event. On the other hand, a child who is extremely social and has an easy temperament may be well adjusted in spite of witnessing a violent event.
Additionally, the same child may react to different situations in different ways. For example, a child may start acting aggressively after he witnesses his mother being beaten up by her boyfriend. In contrast, he may continue to be socially competent even after being homeless for several months.
Participant [maryjo]: What are your thoughts on medicating children under age 5 with ADHD?
Guest [Samantha Wulfsohn]: There is no research on medication for preschool children. However, a recent study demonstrated that medication was the most effective first step to treat ADHD in older children. Research is on its way for younger children. From my own experience, I have seen many children medicated inappropriately and it is often turned to as a "fix it" approach.
Children who are misdiagnosed are often medicated. Additionally, children with ADHD need more than medication. They need to learn how to self-monitor and be more aware of their behavior as well as learn social skills. However, medication can be extremely helpful for children who have a true diagnosis of ADHD even when they are as young as 4 years.
You should be able to find information on the ongoing research at NIMH.
Participant [maryjo]: What are some signs of depression in young children?
Guest [Samantha Wulfsohn]: Maryjo, this can be a tough one because signs of depression in young children are not always the same as what you would expect in adults. Children who are extremely irritable and sad may be depressed. However, they may also demonstrate acting out behavior.
Here is a list of signs of depression in children and adolescents as presented by the American Academy of Child and Adolescent Psychiatry. However, it is important to consider these signs within the context of what you would expect for younger children.
Also, take a look at the DC 0 to 3, mentioned earlier for additional information on mood disorders in young children.
Guest [Samantha Wulfsohn]: Thank you, everyone, for participating tonight. Your questions were great and I have enjoyed talking with you all.
Participant [Question]: What are the signs that a child may need to be evaluated by a professional for mental health problems?
Guest [Samantha Wulfsohn]: Any time a parent or caregiver notices behavioral extremes it is worth looking further into the problem. If a child is doing things that are not typical for their age, and their behavior is getting in the way of the child’s ability to function normally (play, go to child care, explore, etc.) it is worth examining further.
Examples of concerning behavior in preschoolers can include extreme aggression, behavioral hyperactivity, and difficulty calming down. Children who can’t get along with their peers and don’t know how to play may also be demonstrating a need for help.
Additionally, it is important not to forget those “easy” and “quiet” children who can get lost in the system, those who are withdrawn, have flat affect, or cry easily. Finally, anytime you are aware of extreme stresses, loss, or trauma in a child’s life and see a sudden change in their behavior, it may be important to get further help for them.
Participant [Question]: Whom should a parent contact if concerned about possible mental health problems? Can pediatricians diagnose and treat mental health problems?
Guest [Samantha Wulfsohn]: The pediatrician is a good place to start when a parent has concerns about mental health problems. Typically, pediatricians are not trained to diagnose and treat mental health problems, although sometimes they will prescribe medication to young children.
It is best if parents obtain the name of a mental health professional (such as a psychiatrist, psychologist, or social worker) from the pediatrician to address concerns about mental health problems. Also, in seeking out the help of a professional, I would encourage parents to find a provider who has experience with young children.
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