Getting in early: Identification of risk in early childhood

Recent discussion about the potential risks and benefits of screening 3-year-old children for signs of psychosocial and developmental problems raises important questions about the concept of early intervention. Whilst it seems that the focus on youth mental health and early intervention for that age group has become a priority issue, the notion of earlier mental health problems and the need for intervention have been sidelined. Various commentators (ABC News, 2012) have stated that it is inadvisable to screen young children, that it leads to the use of stigmatising, diagnostic labels, and that it is not possible to identify mental health problems in pre-school children. It has been stated (Dunlevy, 2012) that child psychiatrists have contributed to an epidemic of inappropriate diagnoses, such as attention deficit hyperactivity disorder (ADHD) and juvenile-onset bipolar disorder, with the implication that screening young children can only contribute to this. The counterview is that early identification of developmental risk is important if we are to develop programs that reduce risk for the development of mental disorders and that this can be done without the negative labelling of children. Ironically, many child and adolescent psychiatrists are well aware of the pitfalls of premature diagnosis and have raised concerns about the use of diagnostic labels in a way that results in lack of understanding of the environmental and family factors contributing to the child’s difficulties and distress.

It is concerning that there has been minimal consultation with infant and child psychiatrists about these issues; further discussion would contribute to a more sophisticated model of developmental psychopathology needed to better explain the rationale for infant and early childhood services and intervention. In infant mental health circles, there is much discussion about how we can better inform government (and our colleagues) about developmental models and developmentally informed services.

Early developmental risk

Early screening and identification of developmental risk is based on an understanding of the importance of early development and normative developmental processes. Parents and carers frequently seek professional advice about their infant’s or child’s development, and can benefit from support and psychoeducation about normal developmental milestones and challenges. General practitioners, maternal child health nurses and primary care workers are often expert in this area and well placed to provide guidance and to support early parenting. They are also in a position to identify early developmental risk factors in both parent(s) and child. Parental mental health issues, such as depression and anxiety, infant difficulties related to neurodevelopmental factors or poor care, for example, can all be identified early and provide opportunities for early intervention. Ideally, the identification of parental risk factors and their potential negative impact on infant attachment and development should take place in the antenatal period when important preventive work can take place. Clearly this is much more a preventive model as opposed to one that aims to identify problems when they are evident in children. Improved understanding of the importance of identifying parental mental health issues has been reflected in pregnancy psychosocial screening and the identification of conditions such as post-natal depression in the perinatal period.

The science of early development and developmental risk has increased significantly over the last 30 years. The infant (0–3 years) period is one of rapid neurological development and organisation and is seen as a ‘foundational’ period when crucial neurological pathways necessary for healthy psychosocial functioning are wired, literally in response to environmental input (Tomalski and Johnson, 2010). Infancy is also a critical period where particular organising experiences are needed for brain development. Factors such as quality of care and emotional interaction, face-to-face interaction and the availability of a consistent and responsive attachment figure shape early brain development and influence evolving capacities for emotional and behavioural regulation. Neurodevelopment is experience-dependent and occurs in the context of attachment and care-giving relationships, which, if functioning well, maintain the infant with an optimal range of arousal and act to regulate stress. The notion that development occurs in a relational context is a central one in current models and suggests that identification of attachment-related risk is an essential part of early risk screening (Belsky and de Haan, 2011).

Early development and mental health

Early adversity, including attachment disruption, maltreatment and neglect, are associated with poor developmental outcomes and increased risks for the range of mental disorders. Neglect and institutionalisation have been studied extensively in longitudinal studies of Romanian orphans who show clear neurodevelopmental deficits such as decreased social affiliation and emotional processing (Zeanah et al., 2009). Children who have experienced abuse have both structural and functional brain deficits in comparison to non-abused children (De Bellis et al., 1999). Behavioural dysregulation, interhemispheric communication and affect/stress regulation are impacted by stress-related hormones and establish long-term vulnerability to stress. Early trauma appears to be a non-specific neurodevelopmental risk factor for mental disorder, again raising the importance of early identification and intervention (Newman et al., 2011).

Whilst most professionals and the general community have an understanding that traumatic experience and ‘stress’ may have a negative impact on psychological and emotional health, this does not necessarily apply to our understanding of infants and young children where ‘trauma’ is harder to define and signs and symptoms are harder to assess and classify. ‘Diagnosis’ in the very young is not particularly useful if thought about in terms of a DSM-type system, which focuses on clearly delineated syndromes or constellations of symptoms, difficult even in adult populations. Signs of distress and developmental problems in young children may not meet the criteria for specific diagnostic categories and this perhaps is a good thing. What is arguably most important in the assessment of young children is the identification of developmental difficulties, attachment issues, and signs of trauma that are potential indicators of neurovulnerability and adverse developmental trajectories. The idea here is that assessment of psychosocial development in early childhood, based on an understanding of typical development and its attachment context, is a process of formulation of the many factors impacting early development with minimal reference to specific diagnostic entities.

Developmentally informed formulation resists premature diagnosis and reductionist models of mental disorder. Concerns about the perceived over use of the categories of ADHD and juvenile-onset bipolar disorder are cases in point where developmentalists have argued that there are possible multiple pathways to the development of syndromes of behavioural and emotional dysregulation. Disorders of early care and attachment-related trauma are common pathways to the syndrome of neurological and psychological dyscontrol central to these conditions. Premature diagnosis, with the assumption that this is explanatory, may result in foreclosure of thinking about the context of the child’s difficulties and the need for exploration of the attachment context. Syndromes of dyscontrol in young children are often associated with disorganisation of attachment, itself related to parental mental health and psychological issues. Similarly, a developmental understanding makes the concept of bipolarity problematic in the young child where emotional regulatory capacity emerges over the early years and is shaped by parenting, emotional interaction and experience.

Parenting behaviours, emotional responses and beliefs and understanding of the child are a complex constellation of factors that shape the developing brain. Experience-dependent synapse formation, particularly those occurring in response to stress, condition neural networks to produce ‘cascading’ effects through later development. In other words, early adversity, at a neurodevelopmental level, can establish ongoing vulnerability to stress and mental disorder. The impact of abuse and maltreatment on brain development has not been addressed adequately in the current debate and ‘diagnosis’ in the young, ignoring the fact that abuse and trauma are significant factors influencing the presentation of so-called internalising (depression and anxiety) and externalising disorders in children.

A model of early intervention

Intervention in the infant and early childhood period is a key strategy in the prevention of adverse psychosocial outcomes and mental disorder. Continuity from early childhood oppositional and behavioural dysregulation to adult antisocial behaviour is clear and an association with poor parenting and physical abuse is found in the majority of violent offenders. Key domains of personality functioning, such as impulse control, frustration tolerance and empathic capacity can be disrupted by early maltreatment and trauma, implying that early parenting and attachment should be a key mental health strategy. However, infant mental health services (0-3 years) remain the poor cousin in terms of mental health planning and financial support in most parts of Australia, despite increasing evidence of the efficacy of early interventions and the economic benefits of supporting positive early development. Current discussion around the model of adolescent and youth early intervention rarely mentions developmental pathways or acknowledges the known early risk factors for mental disorders. Trauma and child abuse are rarely discussed despite the increasing evidence of their significance. In some ways the current misunderstanding about early childhood screening has also failed to identify abuse and neglect as likely the most significant known risk factors for mental disorder and poor psychosocial outcome. Numerous studies have found significant associations between retrospectively reported childhood adversities and adult mental illness. More recently, McLaughlin and colleagues (2011), Green and colleagues (2011) have found that maladaptive family functioning (parental mental illness, substance abuse, criminality, violence and abuse) tends to cluster and is associated with 44.6% of all childhood disorders and between 25.9% to 32% of later-onset disorders (McLaughlin et al., 2010). This and related findings strengthen the argument for early identification and intervention and the development of adequate infant mental health service responses.

The infant mental health model faces the challenge of advocating for investment in infancy and early childhood when social benefits may not be demonstrated in full for a decade or more. Opportunities for primary prevention and identification of risk factors can be linked to existing services, as with the Healthy Kids Check under discussion, but it is also important to ensure that infants already showing signs of developmental compromise are offered clinical intervention. This is the dilemma facing all screening approaches – the identification of possible problems is only useful here if there are adequate service responses.

Advocacy for infant and early childhood mental health services is a complex task. Whilst early adversity may result in immediate impact, other problems may evolve in later childhood or adolescence. Intervention approaches may be preventive, targeted or the treatment of established conditions. Prevention is a broad goal and approaches range from pregnancy and parenting support to programs for parents with known risk factors for parenting and attachment difficulties. There is a need to balance population-based and so-called ‘high-risk’ approaches and to link maternity, child health and primary care and mental health sectors.

Screening and assessment in infancy and early childhood needs to focus on the broad context of child development. Whilst full details of the proposed 3-year-old screen are not yet released, it is reported to be focused on possible symptoms of externalising and internalising disorders or a broad syndrome approach. Like most screening approaches, this raises further questions about the causes or contributing factors and context of the child’s difficulties. It may result in both false-positive and false-negative responses and needs to be followed by comprehensive assessment. Screening of young children should also include observations of interactions between child and attachment figures and the child’s socioemotional development.

Infant and early childhood interventions aim to influence long-term developmental pathways and target critical developmental periods. For example, if it is known that risk factors for poor infant outcome and attachment disturbances such as maternal anxiety and depression can be identified during pregnancy, antenatal screening and intervention should be encouraged. Other targets include the prevention of child abuse and neglect, support for early attachment and emotional interaction and programs for infants with intrinsic vulnerabilities, such as prematurity or the impact of substance exposure, and for parents with mental illness. Within the broad range of factors impacting on child development, the identification of ‘high-risk’ parents with core difficulties in parenting behaviours and responses is a key strategy for intervention. Dysfunctional parenting can result in disorganisation of attachment and problems in self-development. Parents’ difficulties are frequently related to their own attachment history, specifically by unresolved attachment-related trauma, the themes of which are often repeated in the relationship with their own child. Interventions for disturbed relationships aimed at building sensitive interactions and understanding of the child are a focus of current research and of much clinical interest (Slade, 2006).

Screening and identification, therefore, is only one component of a much-needed infant mental health system of developmentally informed early intervention. Whilst describing this as a ‘mental illness check for toddlers’ (Stark, 2012 ) is misleading and alarmist, it reflects poor understanding of early risk and the difficulty of promoting the better message of a ‘development and attachment check’ for infants and young children. Promotion of healthy child development and better mental health outcomes starts with an understanding of developmental processes and context-concepts that inform our understanding of psychological and emotional disorders.