PROFESSIONAL LINKS
This chapter addresses the following:
Department for Education (2017) Statutory Framework for the Early Years Foundation Stage: Setting the Standards for Learning, Development and Care for Children from Birth to Five. London: DfE.
CHAPTER OBJECTIVES
By the end of this chapter you will understand:
how to identify mental ill-health in the early years;
how to support children with specific mental health needs.
INTRODUCTION
This chapter introduces you to common types of mental ill-health in early childhood and provides some useful strategies that you can use to support children with specific needs. Children who are not mentally healthy are less likely to thrive. Their personal, social and emotional development is critical because it affects every other area of learning and development. A range of factors can affect children’s mental health, including individual, community and family-related factors. Children’s experiences in the setting can also influence their mental health. It is clear that mental illness does not just begin during adolescence. Many problems that are evident in children at the age of 14 are also evident during early childhood. Despite this, there is still a reluctance in society to accept that young children can demonstrate mental ill-health. This chapter begins by examining the aspects of personal, social and emotional development in the Early Years Foundation Stage framework (DfE, 2017) that can influence children’s mental health. It then identifies some key warning signs of mental ill-health that practitioners may notice during their observations of children in a range of contexts. Finally, it examines common types of mental ill-health that children may experience in the early years.
PERSONAL, SOCIAL AND EMOTIONAL DEVELOPMENT
Personal, social and emotional development (PSED) is a prime area of learning in the early years. This is because it underpins all other areas of learning and development. It is the area of learning and development that relates most closely to mental health. Children’s development in the specific areas will be affected by their development in PSED. If children lack self-confidence and self-awareness then this will affect their cognitive, physical, social and emotional development. If they find it difficult to establish relationships with others, this will impact detrimentally on their ability to learn with and from others. If they find it difficult to manage their feelings and behaviour and are unable to adjust their behaviour to fit the context of the setting, this will affect their ability to learn effectively.
SELF-CONFIDENCE AND SELF-AWARENESS
Children that are confident are able to try new activities and take risks. They are able to ask for help when they need it, select resources and learn from their mistakes. Children who lack self-confidence are generally less willing to try new activities and less willing to take risks and this limits their learning potential. They may become anxious and stressed when they are presented with new activities and experiences, and this can then prevent them from benefitting from new opportunities.
Some children may demonstrate signs of attachment disorder. They may have developed insecure, unstable or weak attachments with their primary carer. Consequently, they may feel rejected, unloved and neglected. These early experiences can have a detrimental effect on their confidence and this can result in feelings of anxiety when they are presented with unfamiliar tasks or experiences. As a practitioner you play a crucial role in supporting all children to develop self-confidence and self-awareness. Through establishing warm, trusting and positive relationships with children, you can support them to develop their self-confidence. You can gradually introduce children to new activities and experiences by initially scaffolding their learning to build their confidence. Once they gain confidence, they will be able to undertake tasks and experiences independently. You also play a critical role in teaching children to ask for help when they need it.
Vygotsky’s Zone of Proximal Development (Vygotsky, 1978) refers to the distance between a learner’s actual level of development and their potential level of development. This is the level that the learner is capable of reaching with the support of a more able other. Wood et al (1976) used the term ‘scaffolding’ to describe the support structures that need to be established to move the learner through their Zone of Proximal Development. Adult interaction in child-initiated play is a direct application of scaffolding a child through their Zone of Proximal Development.
MAKING RELATIONSHIPS
Learning in the early years is fundamentally a social process. Learning through play is critical for all aspects of a child’s development. Collaborative learning enables children to learn the skills of negotiation, conflict resolution, regulation, problem-solving, empathy and risk-taking. In addition, collaborative play-based learning develops children’s vocabulary, language and communication skills that underpin the development of their literacy skills. If children are not able to form relationships, then they miss out on the opportunities to develop these skills.
Some children will need greater support to help them to understand how to establish effective relationships. They may have been exposed to models of violent, manipulative, disrespectful and controlling relationships in the home. These children may need to be taught the skills that underpin the development of effective relationships. These include:
turn-taking and sharing;
listening to others;
respect for others.
Practitioners may need to model these skills through intervening in children’s play. Through playing alongside children, you can model explicitly the skills that underpin the development of effective relationships. You can also read stories to children that address the theme of relationships and you can model positive relationships through your interactions with children and adults in the setting. For children who have not been exposed to positive relationships at home, these strategies will introduce them to models of appropriate relationships and support them in adjusting their behaviour when they are in the setting.
MANAGING FEELINGS AND BEHAVIOUR
Children should be encouraged to talk about their feelings. You may need to support them in developing their understanding of feelings by explicitly teaching them about different types of feelings. These include feeling happy, sad, worried, nervous, angry, jealous, excited and so on. Providing children with a ‘feelings curriculum’ will broaden their vocabulary and enable them to name their feelings. Stories that focus on different feelings are also a very effective way of teaching children about feelings. Essentially, children need to know that it is normal to experience negative feelings and that everyone experiences these from time to time. Your role as a practitioner is to provide them with some strategies to help them to manage their feelings. Children also need to be supported to recognise feelings in others and to show empathy. They need to be supported to follow simple rules in the setting, to adjust their behaviour in different contexts and to adapt to changes in routine. Enabling children to manage their own behaviour will help them to learn more effectively in the setting.
WARNING SIGNS
Sudden changes in the child’s mood or behaviour could indicate that a child has a mental health need. However, it is important that you observe the child in a range of contexts to establish whether the problem has been ‘triggered’ by a specific context. It is also important to observe the child over a period of time to identify if the problem is persistent. Common signs of mental ill-health in children include:
changes in mood;
changes in behaviour;
physical signs;
soiling;
drawings that might indicate that the child has negative feelings;
hiding inside clothes to become invisible;
deteriorating attendance or punctuality;
deteriorating profile across areas of learning and development.
This is not an exhaustive list and specific mental health needs have specific warning signs. If you are concerned about a child, then you should discuss your concerns with the designated safeguarding lead or person with responsibility for special educational needs. You should also discuss your concerns with the parent. Some of these warning signs may need to be carefully considered. For example, hiding inside clothes can happen quite spontaneously and might not indicate that children have a mental health need. If this behaviour is prolonged then it might require further investigation. Soling can arise from a physical or medical problem and is common in children from birth to four years old. However, if it extends well beyond this then it might need further investigation.
CRITICAL QUESTIONS
What are the controversies relating to a diagnosis of mental ill-health in the early years?
What are the risks associated with labelling children?
How easy is it to gain a diagnosis of mental ill-health in infants?
It is important to remember that young children may display poor behaviour because they have underdeveloped self-regulation skills rather than poor mental health. If behaviours are short-term, this could indicate that self-regulation skills need further development. If the behaviour is exhibited over a long period of time, this could indicate that the child has a mental health need. It is important to observe the child in a range of contexts and to communicate your concerns with parents, other practitioners, health visitors and other external professionals.
In 2017:
5.5 per cent of pre-school children aged 2–4 years had at least one mental health disorder;
1.3 per cent of pre-school children aged 2–4 years had sleeping disorders;
boys aged 2–4 years were more likely to have mental ill-health than girls.
(https://files.digital.nhs.uk/F6/A5706C/MHCYP%202017%20Summary.pdf) |
ANXIETY
Anxiety disorders range in both type and severity. Children with general anxiety disorder may demonstrate anxiety in a range of situations, while children with specific phobias usually experience anxiety in relation to very specific situations. Some young children may experience separation anxiety; this is anxiety resulting from separation from significant individuals in their lives. In addition, children who experience social phobias tend to experience anxiety in specific social situations. Children with anxiety may display a range of symptoms. These may include:
fearfulness, irritability, panic, breathlessness and sleep deprivation;
headaches;
stomach aches;
tearfulness;
sweating;
being clingy.
Your observations will help you to identify the factors that result in the child developing anxiety. You should set small, achievable goals for the child and praise them regularly when they achieve a goal. You should not feel afraid to talk to children about your own anxieties and how you overcame them. Children’s stories that focus on the theme of anxiety are also a useful way of normalising anxiety because they help children to recognise that other people also experience anxiety.
CRITICAL QUESTIONS
STRESS
Stress and anxiety are often used interchangeably but they are different things. A child may feel stressed but not anxious, although stress can sometimes result in the child developing anxiety or depression. Signs of stress include:
being irritable;
feeling over-burdened;
inability to relax;
being aggressive;
being impatient or becoming wound-up.
Early childhood should not be a time when children experience stress. Children learn better when they are relaxed and free of pressure. Providing children with opportunities to learn in a rich, stimulating and enabling learning environment will reduce levels of stress. Learning through play and learning in the outdoors will also facilitate enjoyment in learning. Despite this, some children may demonstrate signs of stress and the factors that have resulted in this might be situated in the setting, family or community. Providing children with some simple strategies for managing stress will help children to control their stress.
CRITICAL QUESTIONS
DEPRESSION
Depression falls along a spectrum from mild to severe. It can fluctuate depending on personal experiences and it can affect a child’s learning and development across all aspects of the Early Years Foundation Stage framework. Children may start to distance themselves from others, become withdrawn, tearful, quiet and demonstrate low mood. Other common signs include:
displaying lack of interest in activities;
isolating themselves from others;
tiredness;
feeling hopeless or worthless.
The causes of childhood depression are multifaceted and complex. Family factors may be responsible for depression, particularly if children have experienced abuse, neglect, family conflict or parental separation. Children may become depressed when they are separated from their parents during the day. However, there is a distinction between experiencing a low mood and being depressed. Depression affects participation in normal day-to-day activities, whereas people can experience a low mood and function relatively well. Your observations of the child in a range of contexts will indicate whether they have a low mood or are depressed. You can support them by assigning them to a key worker that they are most comfortable with. Establishing clear, consistent routines and engaging them in physical and social activities are also good strategies for addressing depression. Most importantly, you need to establish warm, positive and trusting relationships with children to show them that you care.
Children can experience grief through the death of a parent, sibling, other family member or friend. They might also experience grief following the death of a pet. Children might grieve for friendships they once had and now do not, especially if they have moved to a new setting, town, city or country. Children might feel a sense of loss if they have experienced permanent or temporary separation from their parents or other family members. They might also experience feelings of loss during times of transition, for example, when they move from home to pre-school. Grief and loss might result in anxiety, depression or even conduct disorders.
In relation to grief, practitioners should not be afraid to use the word ‘death’, even with younger children. You might say ‘I was sorry to hear that your dog has died’. It is better to be honest with young children rather than trying to protect them from the truth. When children return to the setting following the death of someone close, it is important to establish a clear sense of routine.
You should not expect the child to grieve for a specific period. Some children need longer than others to grieve. Others will appear to be coping but they may still feel sad. It is often surprising how quickly young children appear to recover following the death of a loved one or a pet. They may not have fully comprehended the permanency of death and the grief might be delayed. This delay might extend over several years. Children’s ability to cope with grief may be affected by the circumstances of the death, their own resilience and access to support networks.
Sometimes following a period of grief, a child may appear to be coping well but something very specific may trigger a memory or an emotion. This might be a birthday, a special occasion, a place or even a happy event that they wish the deceased person could share. You will need to be patient with the child and reassure them that this is not something they should feel bad about. Providing children with the opportunity to hear and read stories that address grief is a useful way of educating them about grief. Stories that address grief and loss through pets are particularly useful for very young children. Some children may respond well to having ‘quiet time’ in a space where they can reflect upon their feelings. You should not be afraid to talk to children about your own experiences of grief.
CASE STUDY
Alex was three years old. His mother was diagnosed with terminal cancer a year ago and had recently died. Prior to the death, Alex’s parents prepared him by explaining what was going to happen. They created a photograph album of special family memories for Alex to keep after the death. When Alex returned to pre-school he was allowed to take the album into the setting. If he felt sad he was allowed to spend time looking at the photographs of his family. On his first day back in the setting, his key worker, Helen, talked to Alex about the death of his mother. Helen explained to Alex that she was sorry to hear about his mother’s death and she spent some time with him looking at the photographs. It was not long before Alex wanted to join in with all of the activities in the setting. He loved going in the writing area and he chose to draw a picture of his mother and write a simple message to her. For several weeks Helen monitored Alex closely to check on his mood. If she noticed that he appeared to be sad, withdrawn, tearful or lonely then she spent some time with him. Helen kept in regular contact with Alex’s father for several weeks and together they agreed on how to support Alex both at home and in the setting.
Signs of self-harm include:
The reasons for self-harm are complex and multifaceted but it is not usually correct to assume that a child will self-harm to gain attention. They might self-harm to divert an emotional pain into a physical pain but rarely do they self-harm to gain attention. Self-harm can also be a form of self-punishment if children think that something is their fault.
If you notice or suspect that a child is self-harming, it is important to suspend negative judgement. Your role is to try to understand the child and find ways of helping them. You should demonstrate empathy. You also discuss your concerns with relevant people in the setting to agree on the most appropriate response.
The work of Bowlby helped to demonstrate the significance of positive attachments between children and their primary caregivers. In cases where loving, caring and secure attachments are not formed because of the family context, this can have a detrimental impact on the child’s sense of self and their behaviour. These children may be withdrawn, demonstrate anti-social behaviour, have low confidence and a negative perception of their abilities. This is not an exhaustive list, but it does demonstrate the range of traits that might be demonstrated.
It is critical that you focus on developing relationships that are consistently positive so that the child can start to trust you and feel safe. The use of praise, encouragement and rewards will support the development of a healthy relationship between the child and the adult. Some children may require specific intervention to support them with the development of their social and emotional skills. Others may require self-esteem enhancing interventions to build a positive sense of self.
Some children demonstrate poor behaviour as they learn to adapt to the behavioural expectations in the setting. Through the support of practitioners, most children learn to adjust their behaviour. Conduct disorders are severe and persistent patterns of negative behaviour. Identifying these early will enable you to provide support to help the child to improve their behaviour. Signs of conduct disorders include:
being argumentative, angry, uncooperative or irritable;
having frequent tantrums and angry outbursts;
being aggressive;
being constantly defiant;
blaming others for things that go wrong;
telling lies regularly;
appearing cruel and lacking empathy for other children;
seeking out risky experiences without thinking about the consequences.
(www.mentallyhealthyschools.org.uk/mental-health-needs/challenging-behaviours) |
You can support children with conduct disorders by providing them with an individual rewards system through which positive behaviour is acknowledged and celebrated. You should involve the child and their parent(s) in establishing behaviour goals and in reviewing progress. Some children might need a curriculum that explicitly teaches them social and emotional skills. Often poor behaviour is an attempt by the child to communicate a need. Most children with challenging behaviour can be supported to change their behaviour patterns and they can learn to adjust their behaviour in different contexts with the right support. You might want to consider keeping a behaviour diary, which will enable you to identify possible triggers for behaviour. Teaching children the skills of conflict resolution is also effective and gives the child some ownership. Demonstrating unconditional positive regard for the child is vital, regardless of their behaviour.
CRITICAL QUESTIONS
What individual factors may result in conduct disorders? Explain your answer.
What family-related factors may result in conduct disorders? Explain your answer.
What factors in the setting may result in conduct disorders? Explain your answer.
CASE STUDY
Tom was aged five and demonstrated signs of conduct disorder. He was frequently defiant to practitioners. He regularly refused to complete tasks and he had started to become physically aggressive towards other children. Tom was exposed to parental conflict in the home and his mother was a victim of domestic violence. Tom’s father was the perpetrator of the violence. Sarah, his key worker, was aware of the situation in Tom’s home and the case had already been referred to social care services.
Sarah focused on noticing when Tom demonstrated positive behaviour. All positive behaviour was rewarded using an individual rewards system that was designed for Tom. Tom was given five opportunities to gain rewards during the day: at the end of each of the two morning sessions, the end of the afternoon session, during lunch time and during the morning break. Stamps were attached to a daily reward chart for positive behaviour and Tom was given a reward at the end of the day if he had gained three out of the five possible stamps.
In 2017:
2.5 per cent of pre-school children aged 2–4 years had a behavioural disorder;
1.9 per cent of pre-school children aged 2–4 years had oppositional defiant disorder.
(https://files.digital.nhs.uk/F6/A5706C/MHCYP%202017%20Summary.pdf) |
There is a widespread perception that children and young people today experience greater mental ill-health than previous generations (Murphy and Fonagy, 2013).
However, increases in diagnoses do not necessarily mean that mental illness is increasing, because increases can be affected by changes in awareness, knowledge, stigma and understanding of what constitutes mental disorder (Rüsch et al, 2012).
SUMMARY
This chapter has identified the common types of mental ill-health in early childhood. It has provided useful strategies that you can use to support children with specific needs. The range of factors affecting children’s mental health have also been explained and examples have been identified and discussed. The chapter provides some key warning signs of mental ill-health and explains what practitioners may notice during their observations of children in different contexts.
CHECKLIST
This chapter has addressed:
the common types of mental ill-health experienced during early childhood;
the factors affecting children’s mental ill-health;
the actions and strategies that practitioners can use to identify and support children’s needs;
key warning signs that indicate potential mental ill-health in children.
FURTHER READING
Vohra, S (2018) Mental Health in Children and Young People: Spotting Symptoms and Seeking Help Early. London: Sheldon Press.