Would a universal check of 3-year-olds prevent or create childhood mental health problems?

The concept of checking children’s development is nothing new. Universal physical health assessments have operated at birth for decades through maternal health services in Australia. The ‘Healthy Kids Check’ has been introduced more recently and is delivered to accompany the 4-year-old immunisations that also assess physical development (height, weight, eyesight and hearing). An expert working group led by paediatrician Professor Frank Oberklaid was recently asked to advise the Australian Government Department of Health and Ageing on options for implementing a 3-year-old health check that would be expanded to include the assessment of children’s social–emotional and behavioural functioning.

The risks to be avoided have been well rehearsed and include inappropriate and inaccurate assessment protocols resulting in over servicing and ineffective referrals. In debating the merit of child checks, an obvious question is the extent to which observations of childhood behaviour are stable across time? We recently reported a large (n = 1684) eight-wave longitudinal study examining the stability of Australian parent observations of child internalising problems from age 3 to 15 years (Toumbourou et al., 2011). Parent reports tended to be stable across the adjacent 2-year study waves, such that groups of children were reliably identified on six different trajectories of childhood internalising. We found 16% of boys and 26% of girls on trajectories characterised by high symptoms at age 3 years. Far from being destined for psychiatric problems later in life, only 5% of boys and girls maintained high-symptom trajectories through to age 15 years, while the majority reduced to lower levels. We found 4% of boys and 16% of girls were on trajectories that had moderate internalising at age 3 years and increased to high levels across puberty to age 15. We have completed previous studies that also reveal the feasibility of classifying trajectories of childhood externalising behaviour (Smart et al., 2005). From our analyses, it can be argued that observations of 3-year-old behaviour do have some predictive value. These analyses show childhood internalising predicts adolescent depression (Toumbourou et al., 2011) and that a range of modifiable factors predict recovery from elevated childhood problems, including higher levels of social competence, better parent and peer relations, and more positive school adjustment (Letcher et al., 2009). Interventions that assess child behavioural, emotional and social behavioural functioning and offer parenting support and psychological assistance to reduce problems have solid evidence for efficacy (Long et al., 1994; Serketich and Dumas, 1996). These interventions typically assess child internalising and externalising behaviour problems using rating systems that show considerable reliability across different observers and settings (parents, health professionals, child care workers and teachers). Ratings focus on physical behaviours (e.g. violence, crying, sleeping, eating), typical emotions (anger, sadness, fear) and social responses (aggression, withdrawal). It is not inevitable that child assessments will increase psychiatric diagnoses or child psychotropic prescriptions, as effective intervention strategies are available to improve parenting skills (Long et al., 1994; Serketich and Dumas, 1996), build child social and emotional competence, and to provide family support to overcome problems and stressors that can undermine healthy child adjustment (Letcher et al., 2009).