Chapter 11,12 summary

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, Children's Mental Health

After reading this chapter, you should be able to;

1. Define mental health and discuss the biological, environmental, and developmental factors that influence mental health in young children,

2. Describe what skills are important for healthy social and emotional development and how early childhood programs can promote these skills.

3. Understand the prevalence, consequences, and academic characteristics of childhood mental health problems.

4. Discuss mental health disorders in children and identify teaching strategies for these children.

Parent and teacher

c o n f e r e n c e s have

been scheduled for the 2- to 3-year-old class group.

Meegan is preparing to meet with Heather's parents. She

has made a special effort to schedule the conference late in

the day to be sure there will be enough time to discuss her

concerns. Meegan is worried about how to talk about the

behavior concerns she has observed. Heather's aggressive

behavior against other children has not stopped in spite

of Meegan's efforts to guide and teach her. Meegan has

intervened more than once when Heather grabbed another

child around the neck. One time Heather picked up a large

block and hit the assistant teacher on the head, and during

i group time, Meegan saw Heather hit Arturo in the face

with her hand, without even turning to look at him;

Meegan believes the parents have also been experienc-

ing difficult behaviors at home because they shared with

her that they take the baby to the grandmother's house

when they need to leave Heather at home with la care-

giver. To prepare for the conference, Meegan has done

some reading about social and emotional development and

behavior and explored some of the services that are avail-

able in the community. She is uncomfortable about sharing

the unpleasant observations she has made, but she is pre-

pared and hopes that the conversation will go well so that

she and the family can develop a plan to help Heather.

i ' : : . •

In this chapter, the terms facial and emotional development and mental health are used i n t e r c h a n g e a b l y to represent a positive state of m e n t a l and emotional wellness in children. This highlights the understanding that j u s t as teachers support children's physical health through p u r p o s e f u l practices, teachers also foster children's men- tal and emotional health through i n t e n t i o n a l l y established environments and pos- itive r e l a t i o n s h i p s and experiences t h a t encourage h e a l t h y social a n d emotional development.

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this chapter, we focus on ways that teachers c o n t r i b u t e to c h i l d r e n ' s m e n t a l . First, we d e f i n e the terminology we w i l l use to discuss children's mental . We then provide an overview of healthy and typical social and emotional

In health h e a l t h d e v e l o p m e n t . Next, we describe how healthy social and e m o t i o n a l development can be promoted in the classroom. Finally, we review some of the more common mental h e a l t h disorders and provide guidance for partnering with f a m i l i e s and m e n t a l h e a l t h professionals to design successful i n t e r v e n t i o n s w h e n c h i l d r e n need special help. Focusing on c h i l d r e n ' s m e n t a l h e a l t h is an i m p o r t a n t teacher responsibility that b u i l d s f o u n d a t i o n s for c h i l d r e n ' s f u t u r e success and happiness.

UNDERSTANDING MENTAL HEALTH

The early years are a s i g n i f i c a n t period for establishing wellness habits and pat- terns, including children's emotional h e a l t h . Teachers are best prepared to impact children's emotional health positively by understanding mental health, what i n f l u - ences it, how it develops across the early years, and how to recognize typical social and emotional development.

Defihing Mental Health

Mentj I health refers to children's abilities to understand and manage their emotions and behaviors and to have healthy relationships with others in age-appropriate and developmental!}' appropriate ways. Children attain mental health and wellness by reaching typical social and emotional developmental milestones, exhibiting h e a l t h y social skills, and demonstrating a b i l i t y to cope with stress or problems (Centers for Disease Control and Prevention, 2015). Mental health is a positive term that refers to the presence of mental or emotional wellness and the absence of mental illness.

Social and emotional development is a part of h u m a n development. It is also l i n k e d to and is considered part of the continuum of men- tal health. Most e a r l y c h i l d h o o d sources consider social and emotional development and mental health to be syn- onymous, or one and the same. The promotion of mental health and the prevention of mental health problems begin in infancy or even earlier. Teachers should recognize, how- ever, that poor social and emotional development does not a u t o m a t i c a l l y suggest that children have m e n t a l i l l - ness. However, c h i l d r e n w i t h atypical social and emotional development have a higher rate of poor health outcomes and higher rates of mental illness. The c o n t i n u u m of mental health includes behaviors t h a t :

• Demonstrate positive social and emotional development, sug- gesting that the child is on course for positive outcomes.

• In iicntt' problems with social and emotional development, also called menial health problems, suggesting t h a t f u r - ther attention is needed to guide the child to more posi-

V

mental health the capacity to experience and manage emotions, form close and secure relationships, and learn and experience life in a healthy way

continuum of mental health range of behaviors associated with positive social and emotional development, mental health problems, and mental illness

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Children benefit from learning adaptability, resilience, and flexibility in the early childhood years.

Chapter 12 Children's Mental Health

mm i m^m

Positive experiences and interactions in the early years help children to form close and

secure interpersonal relationships.

• Imply potential underlying mental disorders, or /7/ncss,. suggesting t h a t the c h i l d s h o u l d be evaluated by a m e d i c a l professional for possible mental health diagnosis and services.

W h e n c h i l d r e n e x h i b i t b e h a v i o r s that a r e t y p i c a l f o r t h e child's age and developmental level, social and e m o t i o n a l devel- opment is u s u a l l y on course. B e h a v i o r s that are not t y p i c a l are more c h a l l e n g i n g to u n d e r s t a n d . They may indicate that ja c h i l d is s i m p l y slower in t h i s area of development at that p a r t i c u l a r time or t h a t the child has not had s u f f i c i e n t experiences tb prac- tice and attain typical social and emotional skills. These chal- lenging behaviors may also be a sign t h a t the c h i l d is at f/s/c for more serious problems over t i m e . The most i m p o r t a n t point is t h a t c h a l l e n g i n g behaviors be i d e n t i f i e d and managed e a r l y to prevent more serious problems later. The boundaries of w h a t behaviors c o n s t i t u t e a p p r o p r i a t e and i n a p p r o p r i a t e develop- m e n t are f u r t h e r clouded based on the e x p e c t a t i o n s of social behaviors in different cultures and neighborhoods. For example, behaviors that one group considers aggressive may be viewed by another group as a sign of strength.

I n s p i t e o f t h e d i f f i c u l t i e s associated w i t h d e f i n i n g w h a t behaviors suggest mental health problems, teachers are respon- sible f o r m a n a g i n g c h i l d r e n ' s b e h a v i o r a n d a d v a n c i n g c h i l - dren's development. In t h i s chapter, we explore these issues

and offer a range of ways teachers play a role in fostering children's social and emotional development. As professionals, teachers remain i n f o r m e d of emerg- ing i n f o r m a t i o n , partner w i t h families, collaborate with m e n t a l health specialists if needed, and design and i m p l e m e n t interventions to promote positive m e n t a l health.

Current Focus on Children's Mental Health

Mental health problems are an important health issue because of the prevalence and early onset. There is also a long-term impact on the child and f a m i l y ' s well-be- ing and an impact on c o m m u n i t y . Between 13% and 20% of f a m i l i e s h a v e a child w i t h a mental health problem w i t h i n a given year (Perou et al., 2013).

Data d e m o n s t r a t e s an increase in the use of services for mental h e a l t h dis- orders in c h i l d r e n , i n d i c a t i n g an increase in prevalence. The long-term i m p a c t i n v o l v e s very serious health issues, i n c l u d i n g suicide, substance abuse, c r i m i n a l behavior, and inability to function effectively in society. Children with mental dis- orders typically have serious challenges at home, w i t h peers, and at school (Perou et al., 2013). E a r l y childhood teachers interact w i t h many children and need spe- cial u n d e r s t a n d i n g about how mental health develops and how to support positive outcomes.

Influences on Children's Mental Health

Children's mental health is influenced by a variety of dynamics that can be appar- ent even in infancy. These include biological and environmental factors, which in turn impact social and emotional development.

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Chapter 12 Children's Mental Health

these

Biological Factors Biolo^ ical factors are traits or characteristics that are specific to the individual child and are related to genetics and proper development of the brain. The importance of

:actors begins in utero. Biological factors include:

tii's, or h e r e d i t a r y factors such as those t h a t i n f l u e n c e p h y s i c a l sixe and appearance and pace of development. Temperament, or the child's style and personality, often described as "easy," "slow to warm up," or "difficult."

• Physical and health attribute*, such as physical anomalies and prematurity. • Type of nutrition, including quality of food. • Brain development, which is growth and development of the brain.

Brain development significantly influences children's mental health. Although the development of the brain begins at conception and does not end until adulthood, the fastest rate of growth is in utero and d u r i n g the first few years of life. During this period, an incredible amount of i n f o r m a t i o n is learned and the structures for f u t u r e learning are established.

Brain development is also strongly influenced by experiences w i t h people and the e n v i r o n m e n t . Interactions that are n u r t u r i n g encourage brain cell development and refine brain cell connections, which set the foundation for positive social and emotional health. Persistent stressful experiences damage n o r m a l brain develop- ment, [causing problems with learning, behavior, and physical and emotional health (Harvard University, n.ci.).

These biological factors interact w i t h e n v i r o n m e n t a l factors described below, creating either positive or negative influences on social and emotional development..

Environmental Factors Children's social and emotional development is extremely vulnerable to environ- mental factors such as these:

• F a m i l y life situations, i n c l u d i n g stress, domestic violence, poverty, abuse, neglect, parental drug use or mental illness, q u a l i t y of the n u r t u r i n g relation- ship, and c u l t u r a l i n f l u e n c e s on parenting.

• Community well-being, including community violence, accessible health care, and social service resources.

• E n v i r o n m e n t a l t o x i n s i n c l u d i n g chemicals such as m e r c u r y and secondhand smoke.

• E m o t i o n a l and social influences such as q u a l i t y of caregiver bonding and f a m - ily interactions. Caregivers include parents and other f a m i l y members such as grandparents, child care providers, and teachers.

Environmental factors such as adverse childhood experiences can exert a strong negative influence on children's social and emotional development. Adverse child- hood experiences (ACEs) are events or stressors that i n f a n t s and young children experience that later contribute to illness, poor q u a l i t y of life, and death. The expe- rienccis are cateeori/ed as abuse, neglect, and household dysfunction. The moreo ACEs an i n d i v i d u a l has, the higher the likelihood of poor health outcomes, w h i c h

• ; i n c l u d e physical and mental health disorders. Figure 12-1 i l l u s t r a t e s the ACEs

caregiver persons who care for Children, such as parents, family members, and child care providers

adverse childhood experiences (ACEs) significant events or stressors that infants and young children experience that later contribute to physical and mental illness, poor quality of life, and premature death

Chapter 12 Children's Mental Health

Death

Scientific Gaps

Conception

FIGURE 12-1

ACEs Pyramid

pyramid, which demonstrates how ACEs early in l i f e leads to a number of conse- q u e n c e s t h r o u g h o u t t h e l i f e s p a r i . T h i s c h a p t e r ' s Safety Segment has more i n f o r - m a t i o n a b o u t the e f f e c t s of stress on the developing b r a i n . H e a l t h y interactions and r e l a t i o n s h i p s w i t h teachers provide i m p o r t a n t opportunities for c h i l d r e n to develop socially and emotionally.

A m a y a , w h o teaches i n f a n t s , knows that some people get frustrated with babies who cry. But she has a special a f f i n i t y for infants and enjoys trying a variety of approaches to create a strong and positive bond with each child. She is usually highly successful in h e l p i n g babies establish a strong attachment and develop alternative ways of communicating.

' Characteristics of Healthy Social and Emotional Development

Early Death

Disease, Disability, '", and Social Problems

Adoption of Health-risk Behaviors

Social, Emptional, & Cognitive Impairment

Adverse Childhood Experiences

toxic stress stress that is stiong. frequent

and prolonged

Social and emotional development begins at birth and progresses actively d u r i n g the childhood and adolescent years. It is h i g h l y dependent on h e a l t h y interactions and relationships with people, i n c l u d i n g f a m i l y members, teachers, and peers.

C h i l d r e n ' s social and e m o t i o n a l d e v e l o p m e n t occurs in a p r e d i c t a b l e pat- tern across the e a r l y years. They emerge t h r o u g h c h i l d r e n ' s m a n y i n t e r a c t i o n s with their family, teachers, and classmates and according to their developmental readiness. Table 12-1 lists social and emotional milestones of i n f a n t s frotji birth to 12 m o n t h s of age. C h a r a c t e r i s t i c s of c h i l d r e n 1 to 8 years of age are l i s t e d in Table 12-2. Overall, social and e m o t i o n a l d e v e l o p m e n t shows a progression from self-centered t h i n k i n g to a greater u n d e r s t a n d i n g of being in relationships w i t h others. U n d e r s t a n d i n g the c h a r a c t e r i s t i c steps of social and e m o t i o n a l

SAFETY SEGMENT The Role of Stress on the Developing Brain

/ Extensive research now demonstrates how stress can change the normal development of the brain

and the body, leading to harmful effects on ledrn- mg, behavior, and health. When children are exposed to

stress, there are known physiological effects such as an increase in heart rate, increase in blood pressure, and increase in the secretion of stress hormones. The harmful effects of stress are diminished when the child has healthy, supportive relationships with adults.

Different kinds of stress have been described: positive stress,'4olerable stress, and toxic stress. Positive stress is short- lived and moderate and gives the child an opportunity to prac- tice how to manage stress. Stress can be positive when children have nurturing relationships with adults who support them. Tol- erable stress is more significant and could cause harm if there

is no supportive relationship available to the child. Examples include death of a family member, a bad accident, or parental divorce. Toxic stress is strong, frequent, and prolonged. It occurs in situations when children do not have access to sup- portive relationships. When children experience toxic stress, it is thought that the neurons in the brain involved with fear, anxi- ety, and impulsivity are overproduced and neurons responsible for reasoning, planning, and control of behavior form fewer connections. This effect on the brain causes lifelong effects on mental health.

The most important aspect of preventing toxic stress or dealing with stress is the presence of positive relationships with caregivers. The effect of high-quality child care ancjl caring teachers can also mitigate the stress that children experience in the early years.

Sources: Notional ScsenSiftc Council on the Devetopina Child, 2014; Shonkoff. 2012, 1 ' : • ' >oi .:.'::J:':;<? '. B( .: •' .': !C 17 from '

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Chapter 12 Children's Mental Health

TABLE 12-1 Social and Emotional Characteristics of Infants Birth

Age B y 6 r jnths

6 to 12 months

Characteristics Focuses on sights, sounds, interactions Communicates needs through expressions, sounds, movements Smiles and enjoys playful interaction Develops attachment when needs are met

Seeks interaction Enjoys initiating and imitating sounds and actions Responds positively to encouragement Prefers familiar routines Has preference for parent and regular caregivers May be shy or anxious with strangers

Sources: Gecber ft al., 2011: Ttubo, 2014.

d e v e l o p m e n t helps teachers recogni/e b e h a v i o r s t h a t are a g e - a p p r o p r i a t e and d e v e l o p r n e n t a l l y appropriate, p r o v i d i n g i n f o r m a t i o n to guide the c r e a t i o n of focused and purposeful activities in the classroom.

Infants Most h e a l t h y children are born with the d r i v e to connect with others. The most criti- cal earliest social milestone is bonding with a caregiver. Attachment theory refers to the process that occurs when an i n f a n t cries and the caregiver responds, resulting in the baby gaining confidence in the caregiver's a b i l i t y to care for and respond to the

attachment theory process that occurs when an infant cries and the caregiver responds, resulting in the baby gaining confidence in the caregiver's ability to care for and respond to the child

,612-2 Social and E Characteristics of Children Ages 1 to 8 Years

Age

1 to 2 years

3 to 5 years

Characteristics

6 to 8 years

Communicates through both words and actions Uses increasingly complex vocabulary Identifies and communicates likes and dislikes Expresses wide range of emotions May struggle with emotions and behaviors in new settings Enjoys interacting with toys Sometimes cooperates; sometimes seeks to be independent Plays alone and alongside others Develops joint attention

Begins to identify and talk about own emotions May express fears or be concerned about "monsters" Enjoys humor, including silly words and word games May be self-centered but begins to show empathy for others Responds well to routines; may need support to make changes Engages in detailed make-believe play; may struggle with fantasy and reality Expresses self through singing, dancing, arts and crafts Seeks interaction with other children

Uses language to share information and describe stories and events Seeks independence, but still has fears Develops a sense of right and wrong Enjoys companionship with adults but prefers to play with other children Wants to be liked and accepted by peers Expresses personal interests and preferred play Develops and repeats intricate play themes and rules of play Plays cooperative games with designated rules

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Chapter 12 Children's Mental Health

joint attention when a baby indicates that he or she wants to share an

experience with the carecjiver by pointing or drawing attention to something

egocentric the perspective of viewing

oneself as the center of the world

1- I

child (Gerber, Wilks, & Erdie-Lalena, 2011). Characteristics typical of the first year of l i f e include:

• Developing a social smile. • Imitating movements and facial expressions. • Expressing communication with face and body. • Responding to others' emotions and expressing joy often.

A f t e r 3 to 4 months of age, i n f a n t s start becoming less interested in basic] needs such as eating and sleeping and more interested in the world around them, provid- ing more opportunities to strengthen relationships with caregivers. These s^gns of healthy development evolve from children's sense of safety and security. A sense of security emerges from the consistent caregiver's w a r m , affectionate tone; f a m i l i a r routines; and positive social interactions.

D u r i n g i n f a n c y , differences in children's temperaments may become more appar- ent and require that caregivers adjust their interactions for each child. Babies of all temperaments need to experience loving, responsive adults, but the manner in which the a d u l t s interact with them may be slightly different. For example, more energetic babies may need more patience and gentle guidance from caregivers, whereas calm, sensitive babies may need to be eased into contact with a d u l t s and other children (Trubo, 2014). By 12 m o n t h s of age, most babies have developed joint attention, which is when a baby indicates that he or she wants to share an experience with the caregiver by pointing or d r a w i n g attention to something (Gerber et al., 2011).

Interruptions in n o r m a l development can result in significant problems d u r i n g infancy. For example, infants who experience hardships or difficulties in attachment w i t h the caregiver d u r i n g t h i s critical period are more likely to demonstrate abnor- mal expressions of emotions, inattention, and distractibility, disruptions in feeding and sleeping patterns, developmental delays, and abnormal relationships with their peers and caregivers as they grow older (National Scientific Council on the Devel- oping Child, 2015). This highlights the need to focus on ensuring t h a t i n f a n t ^ estab- lish a sense of safety, trust, and security as crucial elements of social and em >tional development d u r i n g the first year of life and beyond.

One to Two Years D u r i n g the second year of life, c h i l d r e n develop an image of their social world, which includes f a m i l y , friends, caregivers, and acquaintances. Children at this age view themselves to be at the center of the world. This view7 is described as being egocentric. A l t h o u g h other people interest them, children at this age have no idea how these people t h i n k or feel (Trubo, 2014). For example, 1- to 2-year-old children may play alongside others, but they do not yet interact with purpose or play coop- eratively. Characteristics of social and emotional development d u r i n g the second year of life include (Trubo, 2014):

• I m i t a t i n g behaviors of others. • Being increasingly aware of self as separate from others. • Being increasingly excited about being around other children. • Demonstrating increasing independence. • Beginning to show defiant behaviors. • Showing more separation anxiety u n t i l midyear, when it fades.

Interest in exploration is a characteristic of children in the toddler years, creating a "pushing and pulling" situation that can seem confusing. These children desire more

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Chapter 12 Children's Mental Health

independence and may express defiance when exploration is hindered, while at the same time needing to be confident in the caregiver as a source of security. Exploration

-Hers can be encouraged by providing safe, adequate play areas; encouraging n's participation; and using language to label objects, pictures, and ideas. It is

in tod childr important to i n v i t e these young children into free exploration within established limits.

Cl ildren in t h i s age group need clear and consistent guidance. Typical 2-year- old b e h a v i o r i n c l u d e s challenges such as aggression. However, these interactions need :o be redirected appropriately so t h a t children learn how to manage their emotions. Focused approaches to g u i d a n c e b u i l d on children's n a t u r a l curiosity and tendency to explore while teaching appropriate boundaries. Teaching children the parameters for play, establishing clear limits for behavior, and g u i d i n g children appropriately w i t h o u t harsh punishment or scolding are important strategies t h a t enhance social and emotional development.

Two to Three Years

During the third year of life, children continue to be concerned about their own needs. They are s t i l l developing awareness of others and may not understand how others feel. Characteristics of social and emotional development for this age group include:

• E x h i b i t i n g more sense of i n d i v i d u a l i t y . • Demonstrating more advanced memory in certain areas. • Growing in emotional understanding. • Increasing interest in friendships. • Increasing development of conscience (sense of right and wrong).

P l a y i r g imitation and pretend games are important to social development for this age gioup. Children 2 to 3 years of age tend to p a r t i c i p a t e in p a r a l l e l , or side-by- side, play unless they w a n t to play w i t h a toy that is being used by another c h i l d . However, it is common for 2-year-olds to look at t h e i r playmates and i m i t a t e them. These situations create important opportunities for children in this age group to explore concepts such as sharing, taking turns, and cooperating (Gerber et al., 2011). By 2]/2 years of age, they begin to use much more pretend play in their d a i l y l i v i n g .

C h i l d r e n at this developmental age seek autonomy and e x h i b i t self-assertion. They are most concerned about their own needs and mostly cannot understand how others feel. These are complex challenges, and it is n a t u r a l for children to struggle to m a i n t a i n emotional balance. Negotiating a p l a n to share a toy may begin w e l l , but when it comes to deciding who gets the toy first, the negotiation may result in frustration and impatience. A c h i l d m i g h t exclaim, "1 am sharing, but I want to play with the truck first!" E m o t i o n a l l y , the 2- to 3-year-old period is characterized by mood swings, which are an indication that the child is trying to learn how to control actions, impulses, and feelings (Trubo, 2014).

It is natural for children in this age group to test limits and occasionally lose control. Managing their emotional impulses is difficult; thus, anger and frustration may quickly turn into crying, hitting, or screaming (Trubo, 2014). Understanding that such behaviors are part of children's n a t u r a l struggle to gain social and emotional resiliency and com- petency in difficult situations is important as teachers implement guidance strategies.

Teachers can help children of t h i s age develop healthy emotional skills by set- t i n g reasonable and consistent l i m i t s that a l l o w children to understand the bound- aries (or actions and behaviors and begin to take charge of their actions. O f f e r i n g appropriate encouragement and reinforcement for appropriate behaviors is import- ant. Teachers also need to be prepared to redirect inappropriate behaviors and to

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Chapter 12 Children's Mental Health

Learning to share is a stage in social and emotional development. Even when very young children agree to

share, they may want the toy first.

help children begin to understand how negative behav- iors affect the children around them.

In the opening scenario, Meegan knows t h a t Heath- er's aggressive behaviors in the classroom won't just go away. She understands that it is her responsibility to iden- t i t y specific strategies to guide Heather to more a p p r o p r i - ate behaviors. At the same time, Meegan knows that she must try to recognize and understand the challenges that may be limiting Heather's healthful development.

Three to Four Years

At ages 3 to 4 years, children's sense of identity and secu- rity is stronger and they become more interested in devel- oping relationships with others. Characteristics of social and emotional development for 3- and 4-year-olds include:

• E x h i b i t i n g increased interest in interacting with others. • Using language to communicate wants, needs, and ideas. • Demonstrating greater ability to manage emotions and regulate behavior. • Following rules and showing an interest in pleasing others. • Taking part in more play that involves fantasy and pretend. • Continuing to be interested in having a strong relationship with the teacher.

Children in this age group are increasingly interested in associative play, or play- ing alongside other children and engaging in a similar focus. For example, 3-year- olds might be observed b u i l d i n g blocks side by side. They share the same materials and t a l k about what they are doing, but their play is essentially i n d i v i d u a l . Uuring this time, c h i l d r e n start to become more a w a r e of the feelings and actions of others. They notice if another child is upset and can begin to recognize the consequences of their actions.

For example, when Lindsay asks Ben w h a t w i l l happen if he keeps pushing his truck against Karen's block tower, Ben is able to say, "It w i l l f a l l down." Lindsay fol- lows up by asking, "What do you t h i n k Karen thinks about that?" Three-year-olds are becoming more able to take turns; trade toys; and use fewer tactics such as grab- bing, w h i n i n g , and screaming to get what they w a n t (Trubo, 2014). A v i v i d i m a g i n a - tion begins to develop d u r i n g this period, enabling children to explore a wide range of emotions i n c l u d i n g love, anger, protest, and fear. Imaginary friends are common, and children may shift r a p i d l y from fantasy to reality. Children continue to need the support of teachers to understand the expectations of behavior and to help them learn ways of managing relationships and emotions.

Four to Five Years

C h i l d r e n become very social at ages 4 to 5 years. They begin to enjoy an active social l i f e and may even have a best friend (Cerber et al., 2011). Friendships should be encouraged because these are key o p p o r t u n i t i e s for c h i l d r e n to practice the social a n d emotional s k i l l s t h a t a r e involved i n b u i l d i n g a n d m a i n t a i n i n g rela- tionships. Characteristics of social and emotional development for this a g e j g r o u p include:

• Focusing on social interactions. • Practicing taking leadership roles.

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Chapter 12 Children's Mental Health

• Exhibiting an increasing a b i l i t y to understand the perspective of others. • Demonstrating ability to focus on projects. • Being literal with rules and needing support to understand flexibility.

C Taking part in more complex i m a g i n a r y play.Fcur- and five-year-old children begin to engage in cooperative play in which elaborate games and rules are established, roles are assigned, and the course of play i: wolves negotiation and give-and-take situations. During this time, children develop increased sensitivity for the feelings of others. They are increasingly able to identi y feelings and recognize the impact of their behaviors. Self-confidence is also developing, and children are ready for responsibilities that build their sense of com- petence, such as setting a table or cleaning a play area. This age group continues to need the support and g u i d a n c e of teachers to ensure that all children are included in play and to f i n d security in consistent expectations about behavior.

Five to Eight Years

Children in kindergarten and elementary school enter a time of industrious explo- ration of their world and interest in greater independence. Characteristics of social and emotional development for this age group include:

'-* ̂• Increasing interest in autonomy and independence. • Continuing to judge self on how adults value and respond to what they do. • Beginning to rely on peers tor feedback about what is good and bad. • Demonstrating individual skills and competencies. • Communicating emotions, ideas, wants, and needs.

C h i l d r e n in this age group tend to become involved in projects and enjoy w o r k i n g on them over a period of days, seeing them through to completion. Children also begin to build friendships and social connections outside the family, developing f r i e n d s in the neighborhood and class group.

Cooperative play evolves to a high level as 5- to 8-year-old children carry over play themes from one day to the next. A child may have several good friends, most often children of the same sex, and enjoy frequent contact and "play dates." This is also a time d u r i n g which children may have heated disagreements that emerge and "blow over" quickly; the child who is an "enemy" on one day may be a "best friend" the next. Children are growing in their ability to understand the feelings of others. They are able to nurture younger children w h i l e looking up to older children as role models.

This age range is also a c h a l l e n g i n g "between" age. On the one hand, c h i l d r e n ages 5 to 8 years are seeking greater independence and f i n d pride in their emergent skills, which may be displayed by tattling when others break the rules or "pushing back" and s h o w i n g resistance when given guidance. At the same time, they may still have y o u t h f u l fears such as death, rejection, or failure, and they can be very sensitive to feedback.

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children displaying aspects

of emotional development.

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of self-awareness evident

in this video contribute to

mental health?

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PROMOTING SOCIAL AND EMOTIONAL DEVELOPMENT

G r o w i n g numbers of children spend many hours in early childhood settings d u r i n g their early years, providing s i g n i f i c a n t opportunities for teachers to promote pos- itive social and emotional development. Programs t h a t plan on supporting social

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Chapter 12 Children's Mental Health

and emotional development can contribute to better social skills and behaviors, fewer conduct problems, and improved academic p e r f o r m a n c e (Kend/iora, 2011). Creating appropriate environments, establishing positive relationships, and imple- m e n t i n g strategies that specifically encourage social and emotional development equip c h i l d r e n w i t h the skills they need to be successful in school and in life.

Contributing to Healthy Social Emotional Development

E a r l y childhood programs have an increased focus on l e a r n i n g skills that promote social and e m o t i o n a l development because these skills, in t u r n , promote future success in all aspects of l i f e . These skills include but are not limited to establishing h e a l t h y relationships; self-concept; or self-awareness, self-regulation, and res lience.

Building Healthy Relationships

The relationships children h a v e w i t h their caregivers are c r i t i c a l , and to a large extent, they determine how children flourish later. As discussed previously, these r e l a t i o n s h i p s m o d u l a t e stress hormones in the c h i l d . In a d d i t i o n to these relation- ships, the q u a l i t y of early c h i l d care and education also play i m p o r t a n t roles in the stress hormone response ( N a t i o n a l Scientific Council on the Developing Child, 2014). As children enter and learn to participate in early childhood classrooms, they have o p p o r t u n i t i e s to practice their social skills with people outside their f a m i l i e s . Committed teachers such as Meegan in the opening case recognize the importance of these relationships and guide children in a way that enables them to grow and t h r i v e . Teachers are also important observers and can communicate w i t h f a m i l i e s about the child's a b i l i t y to form and negotiate friendships.

The Collaborative for Academic, Social, and Emotional Learning (CASEL) identifies relationship skills as one of the core competencies for health development. The goal is to help children m a i n t a i n health and rewarding relationships by (Kend/iora, 2011):

• Teaching cooperation. • Teaching c h i l d r e n to resist social pressure that is inappropriate. • Prevent conflict in the classroom as m u c h as possible. • Help children manage and resolve conflict. • Teach children to ask for help when needed.

Finally, skills and trust that children learn from healthy relationships help them a c q u i r e important skills, which are discussed in the next section.

self-concept awdreness or ided o' one's self

self-efficacy set of beliefs an individual

has about his or her capacity to pursue and complete tasks, activities, or other

attainments

i

Developing Self-Concept and Self-Efficacy

Self-concept is an awareness or idea of one's self. Self-efficacy is the set of beliefs an individual has about his or her capacity to pursue and complete tasks, activities, or other attainments. For c h i l d r e n , it is the concept of / can do it! Together self-concept and s e l f - e f f i c a c y help c h i l d r e n develop a sense of who they are and w h a t t h e i r purpose in the world is (a sense of identity).

Each day, children practice skills that can promote their sense of self. Teachers can contribute to these skills. Here are a few general concepts related to self concept and self-efficacy (U.S. Department of H e a l t h and H u m a n Services, A d m i n i s t r a t i o n for Children & Families, 2014):

• Develop a classroom that is welcoming for each child. Give c h i l d r e n opportunities to share aspects of themselves and their f a m i l i e s .

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Chapter 12 Children's Mental Health

Teachers help young children gain social and emotional skills by setting reasonable limits and providing clear

guidelines for behavior.

• Teach children independence with respect to activi- ties of d a i l y living.

• H f l p c h i l d r e n develop a sense of accomplishment.

When c h i l d r e n develop a positive self-concept, they can use other important skills more readily and they will exhibit greater success in both school and commu- nity. The Teaching Wellness activities provide ideas for setting the stage for c h i l d r e n ' s u n d e r s t a n d i n g of their own competencies.

Developing Self-Regulation

Self-regulation is the ability to control one's emotions and to h a n d l e stress, the a b i l i t y to develop i m p u l s e control, and the ability to develop perseverance. It is a process for young children to develop these skills, and as they enter kindergarten, they are expected to develop the capacity to regulate t h e i r impulses and emotions according to the rules of the new setting. For example, with a few gentle reminders, children in kindergarten are expected to learn to raise their hands and wait to be called on rather than calling out an answer to a question. Learning in the school setting relies on children being able to listen to and follow direct ons given by the teacher rather t h a n r u s h i n g f o r w a r d w i t h the task.

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E a r l y childhood teachers can p l a n m a n y activities to h e l p c h i l d r e n learn and practi:e self-regulation skills d u r i n g the preschool years. For example, Su Lin rec- ognized at the beginning of the year t h a t m a n y children in her class would run with excite nent from one activity to another. She found that providing clear instructions and a predictable daily routine helped the children understand expectations. When they heard the five-minute warning bell, they were more able to stop their play and participate in cleanup time before moving on to the next activity of the day. Su Lin continued to offer specific instructions about appropriate behaviors to reinforce her expectations. Over the year, she noticed remarkable improvement. Children's abil- ity to self-regulate enabled them to manage the tasks associated with learning and to develop positive social relationships successfully.

Developing Resilience

Resilience is an i n d i v i d u a l ' s ability to overcome stress and to adapt effectively to stress, adversity, or threats. It can also be defined as the ability to change toxic stress into tolerable stress (National Scientific Council on the Developing Child, 2015). As with other skills, resilience is acquired by experiencing supportive relationships early in life and is mitigated by intrinsic factors such as personality and temperament.

Despite adversity, many children s t i l l overcome and t h r i v e and demonstrate resilience. Studies have shown that there are some common characteristics among those who overcome major challenges. These positive factors i n c l u d e (National Sci- e n t i f i c Council on the Developing Child, 2015):

•'Having at least one stable, n u r t u r i n g relationship w i t h a caregiver. E x a m p l e s include parent, teacher, neighbor, and social workers.

• Helping children develop a sense of accomplishment. • Helping children attain self-regulation and executive skills.

Watch this video of a

teacher helping Alec learn

how to use an eyedropper.

How do her skills help him

develop self-efficacy?

self-regulation the ability to control one's emotions and to handle stress, the ability to develop impulse control, and the ability to develop perseverance

resilience individual's ability to overcome stress and to adapt effectively to stress, adversity, or threats.

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Chapter 12 Children's Mental Health

TEACHING WELLNESS ICanDoIhtags

LEARNING OUTCOME To develop children's recognition of their own competence by guiding them to identify them- selves realistically as people who can do things.

INFANTS AND T O D D L E R S • Goal: Children experience the teacher describing the

child's abilities.

• Materials: No materials are needed.

• Activity plan: Use everyday activities and experiences to encourage, name, and describe the infant and toddler's emergent skills. Use phrases such as "You are drinking milk from the bottle. You know how to drink milk!" or "I see you are looking at the book. You know how to turn the pages."

» How to adjust the activity: Describe the actions of adults, pointing out what the grown-up can do, such as

P R E S C H O O L E R S AND K I N D E R G A R T N E R S • Goal: Children can identify skills they have and skills they

desire.

• Materials: Magazine pictures or clip art showing people doing many different activities, some of which depict skills children can typically accomplish and some that take training or practice. Select pictures that show a range of skill activities, people of various ages, people with special developmental needs, and other features that would be familiar to the children in the group.

• Activity plan: Guide the child to look at each picture and place it in the "I can do this now" pile or the "I would like

S C H O O L - A G E C H I L D R E N • Goal: Children are able to identify many personal skills.

• Materials: Paper, pens, stapler.

• Activity plan: Guide the children to construct an / Can Do Things book that includes drawings and stories about skills they have.

"Your mommy knows how to pack your lunch" or;"Your dada knows how to zip your coat." As children begin to develop language, spend some quiet time talking with the child and remembering all the things the child did during the day. Summarize the list, saying, "You colored on some paper; you ate your snack; you took your nap. You! know how to do many things."

Did you meet your goal? Does the infant enjoy the friendly conversation? Does the toddler begin to respond when the teacher describes "what" the child can do? Does the child provide examples when asked, "Sasha, what do you know how to do?"

to learn to do this" pile. Invite the child to describe one of his or her skills in detail (such as brushing teeth or cutting a banana slice). Help the child imagine how he or she could learn a skill that is in the "like to learn" pile (such as riding a bicycle or baking muffins).

How to adjust the activity: Play a "Can you do this?" game. Take turns asking, "Do you know how to ... jump?" o r " . . . take care of a goat?" Add some silly options: "... how to give a hippopotamus a bath?"

Did you meet your goal? Can children realistically iden- tify their current skills?

How to adjust the activity: Work with the children to identify different kinds of skill "chapters" for their x)ok, such as Caring for Myself, Caring for Others, and Caring for My World. Periodically encourage children to adid to their book.

Did you meet your goal? Is each child able to draw and write about many skills?

Other i m p o r t a n t aspects of resilience are that although some c h i l d r e n are par- ticularly v u l n e r a b l e to stress, they can have a strongly positive response to posi- tive factors. Also, how well a child copes with stress can be specific to situations. A child may cope well with being b u l l i e d but not as well with being separated from a parent. Most importantly, promoting resilience recjuires the presence of supportive relationships (National Scientific Council on the Developing Child, 2015).

Creating Supportive Environments

F.stablishing environments that are welcoming and a t t u n e d to children's develop- ment sets the stage for appropriate social and emotional dev<

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development. M a n y !• tudies

Chapter 12 Children's Menta! Health

uggested that children's social and emotional development is encouraged in hildhood environments that have specific characteristics such as these ( B i r i n - al., 2012; National Scientific Council on the Developing C h i l d , 2014):

gh quality teacher-child relationships with low ratios, gh classroom quality.

have s- early gen c>t

• H 1 1

• M

• Q u a l i t y of attachment relationship between teachers and infants/toddlers.

The characteristics of the school that are most important in mental health pro- motion include the following (Bershad & Blaber, 2011):

• Caring and healthy teacher-student relationships, especially respecting ethnic, cultural, and racial aspects of families.

• Maintaining expectations that are high and age-appropriate. • Clearly written standards that are implemented throughout the entire school. • Using strategies and interventions that are effective and sensitive to children's

needs, including social and emotional needs. • Creating an environment of safety—emotional and physical.

Teachers create welcoming spaces where children play, learn, and t h r i v e by- developing a sense of safety and security and by h e l p i n g children manage their emotions and get along with others. An example is providing space for block play and construction t h a t is not in the w a l k w a y of the d r a m a t i c p l a y center. Other aspects include creating social and quiet areas that allow children to select the setting t h a t meets their needs and encouraging self-sufficiency by providing t o i l e t i n g areas that allow c h i l d r e n to be s e l f - s u f f i c i e n t when it is age-appropri- ate and l a b e l i n g tubs and shelves for toys so that children can h e l p at c l e a n u p t i m e . Young c h i l d r e n recognize environments t h a t are child-oriented and c h i l d f r i e n d l y . These attentions to the physical space c o m m u n i c a t e t h a t c h i l d r e n are welcomed and valued.

Establishing Caring Relationships

D u r i n g the early years, the child-caregiver relationship has the most i m p o r t a n t environmental i n f l u e n c e on a children's mental health. Recent research has also highlighted the v a l u e of the teacher-child r e l a t i o n s h i p as m a k i n g u n i q u e c o n t r i b u - tions to children's social and emotional development ( N a t i o n a l Scientific Council on the Developing Child, 2014). This relationship exerts a positive influence on a child's development when the relationship is responsive and n u r t u r i n g . In the class- room, these contributions are put into action through close and n u r t u r i n g interac- tions between children and their teachers that demonstrate commitment to b u i l d i n g strong and positive reciprocal relationships.

Nurturing Relationships B u i l d i n g n u r t u r i n g relationships is a primary component of healthy teacher-child interaction. It encompasses the essential elements of the teacher's contribution to children's positive mental health: respect, responsiveness, appropriate g u i d a n c e , and positive expectations. For example:

• Providing interesting challenges and encouraging children's n a t u r a l interests to explore and discover communicates respect, which enhances each c h i l d ' s feeling of worth.

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Chapter 12 Children's Mental Health

social and emotional competencies

set of skills thai allow an individual to process,

understand, and regulate emotions, to develop

interpersonal skills, and to use cognitive skills so that lie

or she can be attentive and focused

• Recognizing children's strengths and needs and responding by p u r p o s e f u l l y p l a n n i n g activities and experiences to meet those needs shows value for chil- dren and promotes a m u t u a l l y trusting relationship.

• Communicating appropriate limits and guiding children to positive interactions help children learn how to be positive members of the group and how to build friendships, demonstrating f a i t h in their capabilities.

• S u p p o r t i n g and c a r i n g for c h i l d r e n through c h a l l e n g i n g circumstances and p e r s i s t i n g i n h e l p i n g c h i l d r e n t o l e a r n expresses c o n f i d e n c e i n c h i l d r e n ' s competency.

• Assisting children with stressful circumstances helps children develop resilience.

Teachers also serve as models for c h i l d r e n regarding how to manage d i f f i c u l t situations. When teachers face challenges with ease, children learn coping strategies rather than defeat. Some children are born w i t h conditions that influence their over- all health, such as prematurity or heart defects, and may challenge their social and e m o t i o n a l development. The teacher-child relationship can m i t i g a t e the effect of these conditions on children's m e n t a l health. If a child is born very prematurely, the teacher can provide high-quality stimulation and attention to maximi/e that child's p o t e n t i a l . This focused i n t e r a c t i o n c o m m u n i c a t e s to the i n f a n t a sense of b e i n g valued, demonstrates commitment and love for the child, and models a positive approach to managing challenges. For teachers to provide caring relationships with children, they must also be attuned to their own social and emotional competencies. These are a set of skills that allow an individual to process, understand, and regulate emotions; develop interpersonal skills; and use cognitive skills so t h a t he or she can be attentive and focused. Teaching can be a stressful and demanding job. Managing stress and emotions is needed to support children in stressful circumstances. See t h i s chapter's Policy Pom/ for a discussion on the importance of social and emo- tional skills for teachers.

In her Head Start classroom, J a n tries to model appropriate interactions when she conducts home visits for families of toddlers who have i d e n t i f i e d special! devel- opmental needs. She helps families recognize their child's abilities and accomplish- ments as they unfold and encourages them to enjoy their child's u n i q u e personality.

P O L I C Y POINT Teachers Use Social and Emotional Skills to Manage Healthy Classrooms

Teachers must use many skills to manage a classroom effectively and to promote

healthy development. Surveys have demon- strated unfortunate increases in teachers' level of stress and dis- satisfaction. Social and emotional competencies affect the quality of the teacher-student relationship, influence what behavior is modeled .for children, and influence teachers' classroom organi- zation an3 management.

Stress on teachers also influences learning in the classroom and relationships with children. When teachers and caregivers are

stressed, the quality of the interaction with children becomes less warm and nurturing. Some interventions for teachers have been designed, such as training in emotional regulation, relationship building interventions, and integration of structure and routines that remind teachers of position social and emotional skill strat- egies. Other recommendations include daily practices such as building emotional awareness, using reflection as a daily practice, managing professional and personal stress, and creating a culture of improvement and learning. Teachers arid other school staff can develop strategies together to incorporate these practices.

irce1 • ri.'• Jones, Bonffard, & Weissbourd, 20" 3.

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Chapter 12 Children's Mental Health

Building Attachment Attachment refers to the bonds of t r u s t , care, under- standing, and safety that develop between children and t h e i r c aregivers. The a b i l i t y to develop an a t t a c h m e n t r e l a t i o n s h i p is considered a h a l l m a r k of emotional we!lii2ss. A t t a c h m e n t is a s p r i n g b o a r d for explora- tion a n d f u t u r e l e a r n i n g . C h i l d r e n w h o experience the positive bonds of attachment are able to explore and learn with confidence. They know that their care- taker is close and accessible if needed. Children who form strong attachment relationships are better able to manage separation from their families as they enter the early childhood setting and u l t i m a t e l y are supported to u n d e r s t a n d themselves as u n i q u e h u m a n beings (Bowlby, 1969; Biringen et al, 2012). The quality of the relationship with teachers is associated with academic achievement and social com- petence (Biringen et al., 2012).

Secure attachments also build children's perceptions of trust, value, and self- worth, which are components of personal safety. For example, c h i l d r e n who feel valued are better able to understand the concept of safety rules for themselves and others.

Providing Appropriate Play

Free ajnd unstructured play contributes to children's cognitive, physical, creative, expressive, and social and emotional development. It is considered so i m p o r t a n t to c h i l d h o o d t h a t the U n i t e d Nations Commission on H u m a n Rights has i d e n t i f i e d play I s a right of childhood (Committee on the Rights of the Child, 1991). Chil- dren's involvement in play is one aspect of social and emotional development that is easily observed. Through play, c h i l d r e n are immersed in d y n a m i c interaction and exploration with the objects and people of their world. Play provides oppor- t u n i t i e s for children to p a r t i c i p a t e in enjoyable activities, use their i m a g i n a t i o n s , test ideas, practice dexterity, explore outcomes, and gain mastery. Unstructured play, or play that is not directed by adults, is especially important. It allows chil- dren to be self-directed in d e t e r m i n i n g the r u l e s and procedures involved in their p l a y themes. This inspires an i n d i v i d u a l experience of direction and mastery and encourages social interaction and problem solving. These a c t i v i t i e s result in a sense of accomplishment and cooperation by using skills that teach resilience and negotiation (Milteer & Ginsburg, 2012). The confidence and resiliency t h a t chil- dren develop through child-directed play builds capacities that support them in new situations and challenges. They learn of their abilities to impact the world and apply decision m a k i n g to outcomes.

Play also brings children into contact with other people and provides opportu- nities for them to experience u s e f u l social skills such as t a k i n g t u r n s , waiting, nego- tiating, compromising, and sharing (Milteer & Ginsburg, 2012). Unstructured play allows c h i l d r e n to explore according to their own interests and at their own pace. Children who are less verbal, who are learning English, or who have special devel-

Positive social-emotional tteveloprnent helps children approach learning with curiosity and enthusiasm.

attachment bonds of trust, care, understanding, and safety that develop between children and their caregivers

opme ital needs are equally able to engage in and benefit from play when they are allowed to set their own pace and follow their own interests.

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Chapter 12 Children's Mental Health

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Through play, children learn to use words to express emotion and experience the reactions of others. For example, two 4-year-old girls might begin their f r i e n d - ship this way:

Sophia hears the teacher introduce Althea. "Hey!" said Sophia. "Althea! That sounds like Sophia! I could be your friend!" Althea thinks for a minute and says, "Sometimes mil mom calls me 'Thea.'" Sophia exclaims, "Sometimes nn/ mom calls me 'Phial' I could be i/oitr friend forever!"

From individual exploration to games t h a t involve rules and negotiation, chil- dren practice and learn many social skills through different types of age-appropriate play.

Open and u n s t r u c t u r e d p l a y t i m e is i m p o r t a n t t h r o u g h o u t the early yt'ars. In some settings, however, free playtime is being reduced due to pressures to promote academic skills both in the home and in the early childhood and school setting. Aca- d e m i c a l l y oriented activities have clear benefits for children's learning. When a d u l t - planned and academically focused activities dominate, children's days may become overscheduled, causing children to feel hurried. The trends that promote attention to academic l e a r n i n g rather than play and social interaction are problematic. Free and unstructured play provides m a n y stress-reducing benefits that c o n t r i b u t e to children's resilience and help build social and emotional wellness.

UNDERSTANDING MENTAL HEALTH PROBLEMS

M a n y children experience normal social and emotional development. They grad- u a l l y develop interpersonal skills and learn to manage their emotions w i t h i n the broad range of typical development. However, growing numbers of children are experiencing delays and challenges in social and emotional development t h a t are exhibited through s i g n i f i c a n t behavior problems in the classroom. Teachers rjro bet- ter able to understand and address children's needs by understanding the preva- lence of these concerns and how they are identified and by being f a m i l i a r v\,ith the types of mental health problems that young children may experience.

Understanding prevalence of Mental Health Probl

Most studies of the prevalence of mental health disorders focus on specific disor- ders. For example, the prevalence of depression is 4% (Harrison, Vannest, Davis, & Reynolds, 2012). More generalized studies indicate that between 13% and 20% of children u n d e r the age of 6 experience emotional, behavioral, or other m e n t a l h e a l t h problems. This includes a wide spectrum of conditions t h a t i n c l u d e emo- tional and behavioral disorders as well as mental health disorders. Based on a num- ber of reporting methods, the prevalence is increasing (Perou, 2013). Children from low-income f a m i l i e s have higher rates of m e n t a l health problems.

The most common mental health disorder is A D D / A D H D at 6.8"c>, followed by behavioral/conduct disorders (3.5%), anxiety (3.0%), and depression (2.1%) (Perou, 2013). Also of growing concern is the relationship between mental health disorders in youth and the risk of suicide later. Adolescents with mental health disorders usu- ally exhibit signs of behavior problems or maladjustment in earlier years.

In very young c h i l d r e n , before a diagnosis is made, teachers and caregivers are observing for signs of atypical social or emotional development that is iisually

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Chapter 12 Children's Mental Health

manifested as significant behavioral challenges, extreme d i f f i c u l t y f o r m i n g rela- tions!" ips w i t h peers, or d i f f i c u l t y u n d e r s t a n d i n g a u t h o r i t y or f o l l o w i n g common

)orn rules even after behavior m o d i f i c a t i o n strategies have been employed.classn As wi better

th any health problem, identifying problems as early as possible will result in outcomes.

Reccjgnizing Consequences

M e n t a l h e a l t h problems t h a t begin in e a r l y childhood can develop i n t o seri- ous disorders as children age. Over h a l f of lifetime mental health disor- ders begin in childhood. Children with mental health disorders have » « * * WHAT IF . problems at home, in peer relationships, and in school, a f f e c t i n g all aspects of t h e i r lives. Mental health problems in childhood can lead to substance abuse, c r i m i n a l behavior, and other serious risk-taking behaviors (Perou, 2013).

Even seemingly m i n o r mental h e a l t h problems can i m p a c t children and families. Children with mental health problems often have problems with self-esteem, learning, and relationships with others. They are more likely to experience other health conditions that impact their daily activities and increase their absence from school.'

.* you were asked to be on an early childhood

advisory committee for your community?

What ideas could you offer to help promote chil-

dren's success in school? What strategies might

you suggest to address the gap in social and

*», emotional development that some children

experience?

Understanding Socioeconomic Factors

Social and emotional development and mental health outcomes are closely tied to social, c u l t u r a l , and economic factors. One important and well-documented exam- ple is :he increase in mental health disorders in children l i v i n g in poverty. This also is consistent w i t h the increase in other physical health problems. Other trends that are seen include (National Center for Children in Poverty, 2012):

• In creased visits to the emergency room by children with mental health problems. • Inadequate access to a f f o r d a b l e care for mental health problems. • Less likelihood of Hispanic children having reported a mental health problem. • Treatment received by about half of children with mental health problems.

Characteristics of a child's f a m i l y can also influence mental health and wellness. C h i l d r e n w i t h m e n t a l h e a l t h problems have higher rates of single-parent house- holds, of parents who are unemployed, and of families l i v i n g in poverty. Unfortu- nately, many of these families believe that they are being blamed for the problem. They are also less likely to be involved parents and to be satisfied w i t h their child's education, f u r t h e r complicating the circumstances (Turnbull, T u r n b u l l , Wehmeyer, & Sogrcn, 2013). Teachers are encouraged to offer support w i t h o u t j u d g m e n t and to tap into resources in the community to assist w i t h these circumstances. This chap- ter's Health Hint discusses how maternal depression can be associated with mental health problems in children.

Using Teachers* Observations V

E n h a n c i n g children's social and emotional skills is i m p o r t a n t to academic suc- cess. D u r i n g the early years, teachers help c h i l d r e n develop foundational skills for learning and h e a l t h y development. Teachers spend many hours w i t h children, and they r a v e an i m p o r t a n t perspective on children's social and e m o t i o n a l s k i l l s and

CONNECTION Watch this video of teachers

discussing children who

exhibit attention-seeking

behaviors. What are some

observations and strategies

the teacher uses to deal

development with these behaviors? 3mpson21(gli - : : !o use until 3 t bej o : tl e i • i

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Chapter 12 Children's Mental Health

HEALTH HINT Parental mental health impacts children

Children are vulnerable to people and circum- stances around them in both positive and nega-

tive ways. Conditions such as depression can have an impact on how well parents or primary caregivers establish attachment, manage emotions, and manage conflict within their families. Maternal depression can have both physical and mental health effects on the child. Having a parent with major depression is a significant stressor for a child, essentially an adverse childhood experience, and can have both short-term and long-term impacts.

The best strategy for these stressors is prevention and early recognition. Parental depression, in particular, is more common than previously thought There is a significant stigma associated with mental health problems in parents, and it is far \oo easy for parents to think that they will harm their child. Although parental mental health problems are associated with challeng- ing childhood behaviors, teachers should offer assistance to these families that is appropriate and nonjudgmental. Interven- tions during a child's early years will prevent more significant problems later.

Sources: TunibuB, Turnbill. Wehmeyer, & Shogren. 2013; Rahman, Surkan, CayeLano, Rwagatare, & Dickson, 2013.

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Observing for Positive Development Children who approach learning with interest and enthusiasm and who are com- f o r t a b l e f o r m i n g questions and focusing on outcomes are better able to acquire new i n f o r m a t i o n and a pply new concepts to f u t u r e settings. These are signs of positive social and emotional a d j u s t m e n t t h a t c o n t r i b u t e to children's success in school. The competencies associated with mental health are observable. For exam- ple, in her i n f a n t and toddler class, Sharina recognizes healthy social and emotional development, or "good" m e n t a l health, when she observes C a i t l i n l a u g h i n g and crawling over to interact with Lin Lin. Caitlin shows appropriate interest, enjoy- ment, and curiosity and expresses this through developmentally appropriate emo- tions and actions. To Sharina, this observation is s i m i l a r to the height and weight measurements she takes to understand children's physical health. While physical measurements give clues to physical health, observations of c h i l d r e n ' s interactions with their peers and with adults help teachers understand children's mental health.

Observing for Atypical Development

To establish successful class groups, teachers must develop a wide range of bejhavior management approaches and techniques. Sometimes c h a l l e n g i n g or a t y p i c a l behav- iors can be a sign that children are at risk for more significant problems. To assist teachers in recognizing behaviors t h a t have an understandable cause and those that suggest the potential for social and emotional problems, special focus must be given to observing the child's b e h a v i o r in the classroom setting. Through careful obser- vation, teachers look for behaviors that are extreme, such as excessively aggressive or w i t h d r a w n behaviors, and for emotional responses that are not age-appropriate or t h a t seem atypical. Signs of problems in social and emotional development are demonstrated through behaviors that are:

• Inappropriate or dangerous. • Frequent and reoccurring. • Persistent.

Children's d i f f i c u l t behaviors are often the first indication t h a t a problem with social and emotional development exists. But recognizing behaviors that suggest a m e n t a l health problem may not be s t r a i g h t f o r w a r d . For example, Bob, a teacher in the young preschool room, f r e q u e n t l y observes 3-year-old Sasha acting i sivelv, such as pushing other children in the play yard and knocking ove ompsorci@iit>eity.flc<;.'': . i . ' : ' ' 1-13 71.214.211 authoriZfldrouseunSI3 </2i \^f>m^

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Chapter 12 Children's Mental Health

children's block structures. Bob has been unsuccessful in managing these behaviors and is unsure whether they i n d i c a t e a lack of communication skills or are signs of more serious mental health concerns. He is not alone in wondering how to interpret such behaviors.

D i f f i c u l t behaviors are a common and n a t u r a l experience in e a r l y c h i l d h o o d classrooms. F.ven typical behaviors can be d i f f i c u l t to m a n a g e , and most c h i l d r e n display inappropriate behaviors at one time or another. For young children, under- s t a n d j n g how to participate a p p r o p r i a t e l y in the group setting requires learning the rules and cues for appropriate social interaction. Testing limits as children gain this social knowledge is normal. A core responsibility of early childhood teaching involves guiding children through these aspects of social and emotional develop- ment and helping them learn to interact appropriately.

Appropriate behaviors are related to normal growth and development; they are behaviors that are expected of most children based on their age and developmental mat uri t y. Behaviors that are considered appropriate change as children age. What is understandable behavior for a 2-year-old is not expected behavior for a 5-year-old. In addition, children who experience special d e v e l o p m e n t a l delays may demon- strate behaviors that are understandable given their developmental m a t u r i t y but are not age-appropriate. For example, 6-year-old Sam, who has a developmental disability, may kick another child who is taking a turn on the bicycle—a behav- ior commensurate with Sam's special developmental condition but not t y p i c a l l y expected of a 6-year-old. Teachers need to weigh the behaviors that are observed wi t h children's i n d i v i d u a l age and m a t u r i t y . Other aspects such as children's cul- ture and n u t r i t i o n a l health can also impact behavior. There are common behavioral patterns in children with mental health problems that teachers can look for, such as intern ili/ing and externali/ing behaviors.

externalizing behaviors negative behaviors that are directed against others or things in the environment (for example, displaying atypical aggression, acting out, and being persistently noncompliant)

bullying externalizing behavior when children use physical or verbal aggression to intimidate others

internalizing behaviors problems related to mood or emotions such as sadness, depression, or worthlessness

Externalizing Behaviors

E x t e r r a l i z i n g behaviors are negative behaviors that are directed against others or things in the environment. Examples are displaying atyp- ical aggression, acting out, and being persistently noncompliant. B u l l y i n g is an externalizing behavior when children use physical or verbal aggression to intimidate others. These behaviors are most common in c h i l d r e n w i t h conduct disorder or opposi- tional defiant disorder, as described in the next section (Turn- b u l l et al., 2013).

Internalizing Behaviors

Internalizing behaviors are problems related to mood or emo- tions such as sadness, depression, or worthlessness. C h i l d r e n with i n t e r n a l i z i n g behaviors tend to be referred less to spe- cialists because their behavior is less disruptive in a group or toward others ( T u r n b u l l et al., 2013).

Observing for Mental Health Problems That Impact Academics

A Matter of ETHICS A 6-year-old girl has joined your first-grade

class. You learn that she recently came to live

with her grandparents for an indefinite period of

time while her mom starts a new job in another

state. You notice that the girl is shy and quiet and

seems sad and lonely. She has had difficulty making

friends and rarely plays outside during recess. You

have tried to talk with the grandparents about your

observations, but they are not concerned and do not

want the child to be referred for any "help." You

recognize that you have an ethical commitment to

support the child, but you don't want to upset the

family. What ideas for managing this situation can

you glean from the NAEYC Code of Ethical

Conduct? What will be your next step? What

resources in your community might you

investigate for information

As vvi h physical health, mental health impacts how well a child learns and assistance? and s icceeds in the classroom. There can be a wide range of expecta- tions tor these children academically, but it is more common for them to have

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Chapter 12 Children's Mental Health

low-average IQs. A significant percentage can have low reading and m a t h achieve- ment. Nearly two-thirds of students with mental health problems also have language delays. U l t i m a t e l y c h i l d r e n with mental illness have much higher rates of dropping out of school altogether (Turnbull et al., 2013).

To improve outcome, the stress that causes or contributes to mental health prob- lems in early childhood can be mitigated in the early years. Teachers are i m p o r t a n t sources of information for caregivers, are critical role models, and can be a positive influence in the l i f e of a child with mental health problems.

u,nderstanding Cultural Influences Children's cultural backgrounds can impact the kinds of behaviors that are consid- ered appropriate. W h a t might be considered appropriate behavior in one c u l t u r e may not be understood in another. For e x a m p l e , a Korean A m e r i c a n c h i l d m a y b e taught to hide his or her emotions, causing the teacher to worry that the child is not capable of expressing and managing emotions, a possible sign of problems ii} social and emotional development.

C u l t u r a l v a l u e s also i n f l u e n c e f a m i l y reactions to c h i l d r e n ' s behaviors. For example, parents may allow certain behaviors in the home environment that are not considered appropriate in the early childhood setting. To better understand the cul- t u r a l framewo rk that i n f l u e n c e s children's behavior, teachers should discuss these issues with families. This helps everyone understand whether p a r t i c u l a r behaviors have a recognizable source or i n d i c a t e signs of problems.

Acknowledging the Role of Sleeping and Eating Habits

Behaviors can also be influenced by children's sleeping and eating patterns. Chil- dren who do not receive s u f f i c i e n t rest may show behavior extremes in the class- room. Difficulties with sleep are far more common in c h i l d r e n with mental health problems. Children with sleep problems tend to show more externalizing behaviors and have higher rates of m e n t a l health conditions such as ADHD (Armstrong, Rut- tie, Klein, Essex, & Benca, 2014).

What c h i l d r e n eat can also influence the way they behave in the classroom. For example, children who have not eaten breakfast or who receive a poor diet may demonstrate behaviors such as i n a b i l i t y to concentrate, lethargy, and persistent f a t i g u e . Understanding children's sleeping and eating routines can h e l p teachers u n d e r s t a n d the source of behavioral issues. This chapter's Nutrition Nvtc d h how obesitv is related to childhood m e n t a l health.

NUTRITION NOTE Childhood Obesity and Mental Health

cusses

: While obesity is not technically considered a * psychological condition, many agree that is has

a significant psychological impact, especially on children. Children with obesity have increased rates

of degression and anxiety, but it is not known whether this association is a cause for obesity or a consequence of obe- sity. Children also have more problems with self-esteem, body dissatisfaction, emotional problems, and resilience. These problems can further complicate the condition. When

a child has poor self-esteem, it may be difficult for them to be confident in making healthy choices and in being more physically active.

Caregivers and teachers are encouraged to take the focus off weight by emphasizing a healthy body image and healthy choices and providing opportunities for increased physical activ- ities. Teachers are also encouraged to promote healthy relation- ships in the classroom by not allowing children to target other children who are overweight.

Source: Russeil-Mayhew. McVey, Bardick, & Ireland. 2012 • • . : • • ' . ' . • : ipson21@lit>erty9du) on 5<9<2017 from 143.71.214.211 authorised to use until 3/16/2C1S Use beyond the authorized

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Chapter 12 Children's Mental Health

Using Community Resources

A smajl percentage of children may experience significant behaviors that persist in spite of efforts to guide and manage the behavior concerns. These children may ben- efit from assessment and evaluation by a behavior specialist or mental health con- sultant. However, determining when efforts to manage children's behaviors are not making progress and when additional support is needed can be d i f f i c u l t . For exam- ple, Hal feels as though he is not doing his job as a teacher when Mandy's behavior does not show signs of improving despite his careful efforts. He thinks the principal will question his teaching skills because the problems persist—in fact, they may be increasing—but he is also struggling because every day is getting harder.

When well-planned intervention strategies are not successful in redirecting chil- dren to more positive behaviors, additional supports are needed for both the child and the teacher. To evaluate progress, teachers, families, and others who may be teaming to address the child's needs discuss questions such as these:

• Have the frequency and intensity of the child's behaviors improved? • isithe child able to navigate most of the activities successfully d u r i n g the day

with relatively l i t t l e support, or does a teacher need to be nearby to prevent aggressive acts or i n j u r y ?

• Is • Is

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the child d e m o n s t r a t i n g more positive behaviors? growth evident?

uses i n d i c a t i n g that problems are c o n t i n u i n g mean that more information and support is needed. Referring the child to special services is the next step. Some schools may have counselors or behavior management specialists who help w i t h classroom management strategies while they find other resources.

The teacher's role in m a k i n g referrals is to provide concrete descriptions of the behaviors that are problematic and information about what is working. Even after referrals are made, the teacher's responsibility to the child continues through addi- tional efforts to manage and guide behavior. In the example above, Hal f i n d s t h a t t a l k i n g with other teachers about strategies and support resources is one way for him to boost his confidence and m a i n t a i n his motivation. Advocating for additional training or the temporary assistance of an aide is another way that teachers obtain support to better teach children with mental health problems.

CHECK YOUR UNDERSTANDING 12,3

Click here to check your

understanding of the prev-

alence, consequences, and

academic characteristics of

childhood mental health

problems.

MENTAL HEALTH DISORDERS IN EARLY CHILDHOOD

Childj-en who experience m e n t a l h e a l t h problems sometimes display s i g n i f i c a n t behavior challenges. These are behaviors t h a t are problematic, out of the ordinary, frequent, persistent, and sometimes dangerous. Teachers are an important source of information for parents and health care providers regarding the child's social behav- iors and/or symptoms of mental health problems. However, medical profession- als m<|ke the diagnosis of mental h e a l t h disorders. M a k i n g a d e f i n i t i v e diagnosis of mental health problems is complex. It involves a broad review of biological and environmental factors, children's age and development, and assessments of how children function in the school and home environments. Sometimes these diagnoses are made over time.

U n d e r s t a n d i n g some of the m e n t a l health disorders that may occur d u r i n g children's early \ears provides teachers with a general understanding of the range

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Chapter 12 Children's Mental Health

reactive attachment disorder

condition that occurs when a child's basic needs for

attachment have been denied or neglected, resulting in

severe problems with social interactions

of conditions that may affect children's mental health and behaviors in {he class- room. Under the I n d i v i d u a l s with Disabilities Education Act (IDEA), the term emo- tional disturbance is used to refer to mental health conditions. The more common mental health disorders identified among young children are discussed in the fol- lowing sections.

Reactive Attachment Disorder

Reactive attachment disorder occurs w h e n a c h i l d ' s basic needs for a t t a c h m e n t have been denied or neglected, resulting in severe problems w i t h sense of self and with establishing healthy relationships. It can be caused by c h i l d abuse or neglect. Children at h i g h risk for a t t a c h m e n t disorder are ( N a t i o n a l I n s t i t u t e s of H e a l t h , U.S. National Library of Medicine, 2014b):

• Children of parents who are intellectually disabled. • Children whose parents have very poor parenting skills. • Children who have had frequent changes in p r i m a r y caregivers, such as l i v i n g

in m u l t i p l e foster homes in early years. • Children separated from primary caregivers or placed in orphanages.

Symptoms of attachment disorder include avoiding contact with caregiver, hav- ing d i f f i c u l t y w i t h being comforted, and showing no interest in social interactions. E a r l y diagnosis and treatment is essential and requires counseling for both the child and caregiver and reinforcement of healthy relationships.

Behavioral Disorders of Childhood

Some mental h e a l t h c o n d i t i o n s f a l l u n d e r a behavioral category simply because m a n y of the manifestations are related to the child's behavior in a group setting, in relationships w i t h teachers, or in relationships with peers. All children misbehave, but b e h a v i o r disorders are more serious and are m a n i f e s t e d by symptoms t h a t are m o r e severe a n d last longer t h a n w o u l d t y p i c a l l y be expected in n o r m a l development.

Attention Deficit/Hyperactivity Disorder attention deficit/ Attention deficit/hyperactivity disorder (ADHD) is a condition characterized by

hyperactivity d i s t r a c t i b i l i t y , persistent lack of attention, impulsiveness, and hyperactivity. The condition'chlllctlrSd bj most i mP°r t a n t characteristics of this c o n d i t i o n are (Efron et al., 2014):

• D i f f i c u l t i e s in social interactions. • Academic underachievement. • Association with other mental health problems.

A D H D a f f e c t s a small percentage of very young c h i l d r e n . Prevalence rates and more discussion of symptoms and treatment are included in Chapter 11. Treatment for ADHD includes classroom modifications and medications; however, the appro- priateness and effectiveness of treatment strategies continues to be researched.

Teachers may be asked by parents, providers, m e d i c a l specialists, or men- tal health providers to describe their observations of the child. This is i m p o r t a n t in diagnosis and treatment. ADHD is associated not only with other mental h e a l t h conditions such as depression, but also with other behavioral conditions such as conduct disorder.

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restlessness, persistent lack of attention, impulsiveness, and

hyperactivity

Chapter 12 Children's Mental Health

Oppositional Defiant Disorder

Symptoms of oppositional defiant disorder u s u a l l y start by age 8. The most com- mon characteristics include propensity to argue with people in authority, abnormal outbursts of anger, a bad temper, and d i f f i c u l t y making and keeping friends. These children are frequently in trouble. It is caused by a combination of factors related to biology and social and psychological circumstances ( N a t i o n a l Institutes of Health, U.S. National Library of Medicine, 2014a).

The most important form of treatment is mental health referral involving coun- seling and possibly psychiatry and medication. The best form of prevention is for a child to have caregivers who offer consistent and reasonable rules while avoiding harsh or inappropriate punishments. Children who are abused or neglected are at high risk for developing t h i s condition.

Conduct Disorder

Conduct disorder is characterized by impulsivity and lack of empathy. Symptoms i n c l u q e breaking rules frequently, being aggressive or cruel toward other people and animals, lying, setting fires, or v a n d a l i z i n g . This disorder has been associated with child abuse, parental substance abuse, and poverty. As in oppositional d e f i a n t disorder, conduct disorder is more common in boys (National Institutes of Health, U.S. National Library of Medicine, 2013). These children have a high risk of devel- oping other m e n t a l h e a l t h problems such as depression and personality disorders. Early jrecognition and treatment is imperative.

oppositional defiant disorder behavioral condition characterized by a propensity to argue with people in authority, abnormal outbursts of anger, a bad temper, and difficulty making and keeping friends

conduct disorder behavioral disorder characterized by impulsivity and lack of empathy. Symptoms include breaking rules frequently, being aggressive or cruel toward other people and animals, lying, setting fires, or vandalizing

Implications for Teachers

B e h a v i o r a l disorders can be some of the most d i f f i c u l t disorders to m a n a g e in a group setting. Often a behavioral specialist or mental health consultant is needed to develop appropriate behavioral management strategies. Children often need fre- quent and recurrent reminders of how to behave and how to manage their emo- tions. Communication w i t h parents is important. When the parents understand the behavior management plan and can replicate it at home, children often have bet- ter outcomes. Children should understand expectations clearly and be reminded of them repeatedly.

Anxiety Disorders

T h i s is another category of mental health disorders that includes generalized anxi- ety disorder, separation anxiety, obsessive-compulsive disorder, and post-traumatic stress disorder.

Gene'aiized Anxiety Disorder

Anxiety is a common emotional response, but when it is persistent and experienced with ^;reat intensity, it is considered a problem. A n x i e t y disorder is c h a r a c t e r i z e d by excessive worry a n d / o r fear (Turnbull et al., 2013). Treatment for anxiety disor- det;s may include cognitive problem solving, behavioral therapy, or medications. Cognitive problem solving might include discussing the potential realities of a fear and i d e n t i f y i n g ways c h i l d r e n can manage them, such as helping a child explore a fear of the red light on the smoke detector. Behavioral therapy involves h a v i n g children gradually face their fears, such as helping a child practice making changes in routines.

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Chapter 12 Children's Mental Health

generalized anxiety disorder

a rnenldl health disorder causing excessive worry and/

or fear

C h i l d r e n w i t h g e n e r a l i z e d a n x i e t y disorder express excessive worry about m a n y things, including f u t u r e events, potential dangers such as earthquakes, and promptness. I n the e a r l y c h i l d h o o d setting, t h i s may be seen when the class is p r a c t i c i n g for a fire drill. For example, Cathy, a 4-year-old, may begin displaying anxiety as soon as she sees her teacher bring out the home-style smoke alarm that he w i l l use at group t i m e when they p r a c t i c e e v a c u a t i n g the classroom. Cathy worries about the loud noise the smoke alarm makes. Her teacher notices her dis- comfort and sets the a l a r m in a cupboard u n t i l group time. Then he asks Cathy if she w o u l d like to push the button to m a k e the a l a r m sound, putting her in con- trol of the s i t u a t i o n , or if she would like to cover her ears, g i v i n g her an option to reduce the sound of the alarm.

Separation Artxie^ Although common in infants and children up to 18 months of age, separation anxiety d i m i n i s h e s as c h i l d r e n age and is not considered typical of older children. It is characterized by an extreme need to be near the parent or home. Behaviors may i n c l u d e i n a b i l i t y to sleep alone or fear associated w i t h separating from the parent when being left in the early childhood setting.

Obsessive-Compulsive Disorder Children with obsessive-compulsive disorder (OCD) d i s p l a y obsessive and repetitive behaviors such as repeated h a n d ! w a s h - ing, insistence on routines such as having the teacher stand in a certain plac£ at the door during arrival and departure, and insistence on having things in their place. Teachers may also notice that children use nonsense words or sounds and that they describe recurring thoughts and themes m u c h longer t h a n would be of interest to most children.

Post-Traumatic Stress Disorder Post-traumatic stress disorder (PTSD) occurs after children have experienced or been exposed to a t r a u m a t i c experience such as extreme violence in the home or neighborhood or frequent instances of m a l t r e a t - ment. As a result, children may be extremely worried, v i g i l a n t , and tense. This can be observed as the child watches others from the edge of play. The teacher m i g h t also notice that the child constantly keeps an eye on the teachers and parents as they come and go, noticing the d e t a i l s of what everyone is doing. Children who s u f f e r from PTSD have d i f f i c u l t y relaxing and enjoying their play Teachers assist by b u i l d i n g children's sense of security, as in this example:

Helena, teacher of the class for 3-year-olds, known that Zack has experienced violence in Jtis home, 'lack and his mother now live in a "safe" house for women and children TC//O have suffered from domestic violence, and he does not get to play outside very often due to their current living situation. Zack appears tense and is unable to enjoy playing in the preschool. Helena makes arrangements with her coteachers to take Zack outside to play for W minutes on his own at the beginning of every day. She runs and plays ball until him and encourages him to climb and swing. After a few days of this routine, she sees that Znck is relaxing. They agree to invite a small group of children oulside,to play with him the following day.

Approaches such as this acknowledge children's struggles and provide an option for w o r k i n g through fears in acceptable ways.

Implications for Teachers

Teachers can use a number of strategies on c h i l d r e n w i t h a n x i e t y to m i n i m i z e t h e i r symptoms. Children w i t h a n x i e t y disorders are more l i k e l y to worry and are less able to regulate their emotions. Thev can also become easily f r u s t r a t e d .

• • : • • • (nthompsordQiiberty 80uj onw9.'2017 from 143 7 1 214.211 authortzacrto use until 3/16C019 Use beyo*«nhe authorized user or valid subscription date represents a cspyn;.

separation anxiety inability to steep aione or fear associated with

separating from the parent when being left with other

caregivers or teachers

obsessive-compulsive disorder

a type of anxiety disorder causing obsessive and

repetitive behaviors such as repeated hand washing and/

or insistence on routines atypical for age

post-traumatic stress disorder

a disorder that occurs after children have experienced or been exposed to a traumatic experience such as extreme

violence in the home or neighborhood or frequent instances of maltreatment, resulting in extreme worry,

vigilance, and inability to manage normal stress

Chapter 12 Children's Mental Health

Teachers can do the f o l l o w i n g ( M i n n e s o t a Association for C h i l d r e n ' s M e n t a l Health, n.d.):

• When students worry about deadlines, offer some flexibility. • Ask parents what works for their child. • Keep a routine/schedule.

' • Ask children to complete their work, but balance that with flexibility. • Offer clear expectations and check in with students to make sure they under-

stand the expectations.

Mood Disorders

Mood disorders are characterized by s i g n i f i c a n t changes in mood—depressed or mood disorders elevated or both (Turnbull et al., 2013). They are complex and are treated with a disorders causing abnormal

. . . . . , . , , - j • f l u c t u a t i o n s i n mood variety of therapies. Mood disorders include bipolar disorders and depression.

Bipolar Disorder Extreme f l u c t u a t i o n s in mood and energy are characteristics of b i p o l a r disorder. Children w i t h b i p o l a r disorder may have long periods of n o r m a l behavior and then swing to h i g h l y depressive behaviors and then to extreme manic episodes (high-energy swings) (Ball, Bindler, & Cowen, 2013). The types of behav- iors and how they mav be exhibited in the classroom are described in Table 12-3.

Bipolar disorder is very rare in the early childhood years, and it is thought to be associated w i t h an underlying biological condition; however, it is d i f f i c u l t to pin- point a specific cause. A l t h o u g h it is rare, its symptoms often begin in early child- hood as s i g n i f i c a n t behavioral challenges. Treatment for bipolar disorder includes medication and various therapies such as cognitive and behavior therapies and f a m i l y therapy, which are often combined with medications.

Depression A mental health disorder that causes disturbances in mood is known as depression. Children with depression can display a wide range of behaviors includ- ing sadness, i r r i t a b i l i t y , anger, changes in appetite, fatigue, problems sleeping, and recurring physical complaints. Depression can affect many aspects of health and vvellness, including growth and development, behavioral problems, academic per- formance, and relationships. It is more commonly associated with other mental health diagnoses such as ADHD.

D e t e r m i n i n g the a c t u a l cause of depression in young c h i l d r e n can be very d i f f i c u l t because no definitive test is available. Evidence suggests t h a t u n d e r l y i n g

TABLE 12-3 Behaviors Associated with Bipolar Disorder

bipolar disorder mood disorder characterized by long periods of normal behavior and then swings to highly depressive behaviors and then to extreme manic episodes

depression a mood disorder causing d wide range of behaviors including sadness, irritability, anger, changes in appetite, fatigue, problems sleeping, and recurring physical complaints

Behaviors

Depressive behaviors

Manic behaviors

Description

• Passivity. • Difficulty sleeping or eating. • Feeling worthless.

• Unpredictably switching to manic behavior.

• Excessive high energy.

• Risky behavior.

• Unpredictably switching to depressive

behavior.

Classroom Examples

• Child shows little interest in toys or other children.

• Child appears excessively tired; is not interested in snacks or meals,

• Child expresses self-doubt; can't be encouraged to participate.

• Child makes unusual movements, wildly running, jumping, calling out,

moving from activity to activity.

• Child is unusually aggressive.

• Child is not sleeping much.

• Child tests boundaries; climbs and uses toys and equipment without

regard to safety.

Sources: Ball, Bindler, & Cowen, 2013, Heward, 2013. omps Inompson21@li!>erty.9flu} on 5'9'20KMror« 143,71.214.211 »uS .

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Chapter 12 Children's Mental Health

WHAT IF ... it is early in the school year and you

realize that one of your second graders,

Raymond, spends the opening class meeting

time staring at the floor. He never participates,

and when you try to engage him, he shakes his

head, indicating that he doesn't want to speak.

What can you do to help Raymond engage . *

with you and his classmates?

biological causes such as changes in brain chemistry might affect.a child's mood. Depression can also occur in response to e n v i r o n m e n t a l situ-

ations such as parental depression, c h i l d abuse or neglect, parental '•t substance abuse, f a m i l y problems, low socioeconomic or education

% levels, and loss of a parent or sibling (Tang & Pinsky, 2015)j M e d i c a l p r o f e s s i o n a l s diagnose depression, g i v i n g careful

attention to the child's medical history as well as details related to .* behavior, peer relationships, and behavioral symptoms. The] length

of time the child's daily f u n c t i o n i n g has been impaired a,nd the presence of specific symptoms such as sleep disturbances, change in

appetite, or thoughts of death are also considered. Sometimes f a m i l i e s

FIGURE 12-2 Children's drawings may provide clues to how they are feeling. Other observations are needed to determine whether this is a sign of depression or another mood disorder.

(I

ask teachers for input regarding their observations when they have worries about a child's behaviors, such as the potential for depression.

Implications for Teachers Teachers may be involved in logging children's classroom behaviors to help inform medical providers and mental health specialists about the child's participa- tion. Teachers also support children with bipolar disorder by establishing familiar r o u t i n e s and g u i d i n g them to m a n a g e extreme behaviors by offering a p p r o p r i - ate choices. Figure 12-2 shows an example of a child's d r a w i n g t h a t should raise red flags for a teacher. Although teachers do not make diagnoses, they do have a responsibility to support f a m i l i e s by discussing their concerns, referring them to professional assistance, and working to address children's issues in the classroom.

Teachers' Role in Children with Mental Health Disorders

C h i l d r e n who are preschool age and younger may demonstrate f r e q u e n t arjicl per- sistent behaviors such as hitting, kicking, biting, and throwing toys or f u r n i s h i n g s at other children and teachers. School-age children may display aggressive behaviors such as h a r m i n g a n i m a l s ; starting fires; or fighting, b u l l y i n g , and showing other

forms of hostile physical or emotional interactions. Teaching children w i t h these behaviors can be very d i f f i c u l t because they introduce distress, discord, and upset in the classroom.

Significant behavior challenges require a great deal of the teacher's attention and energy to manage while at the same time t r y i n g to m a i n t a i n a learning environment for the larger group of children. Sometimes teachers believe that they are only "containing" children's behaviors and not helping them to move on to more positive ways of showing emotions and i n t e r a c t i n g . Teachers need a range of supports i n c l u d i n g ways to promote appropriate behaviors, approaches to man- age them when they occur, and strategies to direct c h i l d r e n from i n a p p r o p r i a t e to a p p r o p r i a t e behaviors. They need to understand the resources that are available to them, such as families and mental health professionals.

Demonstrating Sensitivity

This is an important aspect of all early childhood pn S3 but is especially needed when addressing m e n t a l

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grams, health

Chapter 12 Children's Mental Health

issues. Parents are often hesitant to discuss mental health issues. Some may t h i n k that mental health issues are not as "real" as physical health issues and believe that people should be able to "fix" their own problems. Families want t h e i r children to be acqepted by others; they may feel dismayed and embarrassed when their child displays behaviors t h a t are out of the ordinary, aggressive, or problematic. If a men- tal health issue is i d e n t i f i e d , parents may wonder if they are to blame. They may find it difficult to reveal this situation to others, and they may not know what to do about it.

Active and supportive c o m m u n i c a t i o n that includes being sensitive to u n i q u e f a m i l y experiences and perspectives is key to n a v i g a t i n g discussions of children's mental health challenges successfully. At times, special creativity and problem- solving strategies are needed. For example, language barriers can make communi- cation about children's mental health problems more complex. Discussions may use words and language that are not t y p i c a l l y part of everyday communication. Special efforts are needed to ensure clear communication, such as obtaining the support of bilingual family members or qualified interpreters.

At other times, teachers may need to approach situations with flexibility, good humor, and understanding. Some children with mental health problems have d i f f i - culty being f l e x i b l e or a d a p t i n g to rules that are d i f f e r e n t in different settings. For example, a child may arrive at class wearing a Halloween costume even though the teacher has specifically asked families not to send their child WHAT IF to school in costume. The parent mav report that the child insisted

.1 • a mother of a c h i l d in your care blamedon w e a r i n g the costume, s t a t i n g that this was the only way he ..» or she could get the child to school. It is easy to be frustrated when it seems that parents, too, are not " f o l l o w i n g the rules." However, in this situation, recogni/ing the challenges the f a m i l y "« faces in m a n a g i n g the child's d i f f i c u l t behaviors (and drawing on good minor and understanding rather than f r u s t r a t i o n ) helps the teacher and family negotiate the issue together. This builds a bond of m u t u i i l u n d e r s t a n d i n g a n d j o i n t problem solving.

family problems on her child's poor social

development? How might you explain

more healthful ways to approach the child

and family's challenge? What ideas do you

have to help the parent find support for

*.»•, the family problems mentioned?

Understanding Successful Integration

Many children with mental health problems participate successfully in early child- hood classrooms. This success is founded on the attitudes and supports provided by the early childhood setting and teachers as well as the candid involvement of families.

Successfully i n c l u d i n g c h i l d r e n w i t h mental h e a l t h problems also requires that teachers, f a m i l i e s , and program staff all see value in the participation of such children. This requires special efforts to create a common commitment to all chil- dren. Teachers are i m p o r t a n t in promoting this sense of community and acceptance among all children in the class. To accomplish this, they must address two issues: They must establish open and candid communication with the families of children who have mental health problems, and they must encourage other f a m i l i e s to be welcoming to children with social and emotional concerns.

Suppbrts Needed from Families

Teachers need the support of families whose children are experiencing mental health problems. These families must be openly communicative and candid about t h e i r child'; strengths and challenges so that teachers will know how to plan for successful

ition and how to manage potential challenges in the classroom. Both teachers 5SOR21@IWsrt£«au7on 5/9/2017 frofi- f«3.7 11 authorized ic use unii; 3/1S/2019 CJS« b*y<

Chapter 12 Children's Mental Health

WHAT I F . . . a parent did not disclose that her child

had a mental health disorder until after the

child was enrolled in your class? Would this

influence your relationship with the child

or parent? Upon learning of the disorder,

how would you respond? ^ , »

functional behavioral assessment

a focused process to reflect on, describe, and define what

is occurring with respect to challenging behaviors in the

early childhood setting

and parents may have fears related to the child's participation in the classroom. They may worry about d i f f i c u l t behaviors that will be hard to manage or

* » , that the child will be unsafe or not accepted by other children. Other issues to keep in mind are c u l t u r a l diversity and how it

*» relates to mental health as well as stigma which may often be asso- ciated with mental health problems.. Parenting styles, expecta-

/ tions of personal boundaries, and gender roles are all aspects that influence cultural and f a m i l y expectations for children's behaviors.

These need to be c a r e f u l l y explored and understood to facilitate an appropriate interpretation of behaviors. It can be challenging to n a v i g a t e

situations where the teacher observes problematic and possibly dangerous behaviors that the f a m i l y views as "typical" and appropriate. Consider this example:

Hector has been teaching 3-year-old Davonne to interact with the other children in the class without pushing and hitting. Davonne is beginning to control his impulse to hit by using his words. Davonne's dad arrives to pick him up from the play yard. Davonne's friend Karl runs In/ and pushes Davonne saying, "Try to catch me!" Davonne clenches his f i s t s and says, "No pushing!" Hector is sorry that Davonne has been pushed, but he is happy to see that Davonne responded appropriately. Before lie can get close enough to comfort and encourage Davonne, Davonne's dad grabs Iris son and gives him a shake, saying, "When someone hits you, you hit him back!" As Hector approaches the pair, quickly trying to summon the words to explain the behavior plan he has been working on, he realizes that Davonne's dad has been left out of the discussion.

The successful involvement of children w i t h mental health problems also relies on the positive attitudes of families whose children are typically developing. Cre- a t i n g a classroom motto that "everyone is welcome" is one way to i n t r o d u c e the concept t h a t all c h i l d r e n have a place in the early childhood setting. Offering social events that focus on helping families get acquainted builds a sense of common experience and togetherness. Families may be more resilient or "forgiving] when they occasionally observe a c h i l d displaying challenging behaviors if t h e y know and appreciate one another.

Finally/ all f a m i l i e s need to be able to see the concrete ways in w h i c h teachers are working to build cooperation and harmony in the classroom. Age-appropria :e class group meetings where c h i l d r e n discuss classroom rules or make a list of appropri- ate behaviors demonstrate that teachers are working to educate all children about how to be an appropriate member of a community.

Conducting a functional assessment

When a child's behavioral challenges are recognized as atypical, teachers use a focused process to reflect on, describe, and define what is o c c u r r i n g . This is called functional behavioral assessment. Features of f u n c t i o n a l assessment include ( T u r n b u l l e t a l , , 2013):

• Describing the child's behaviors: What? When? Where? How often? Intensity?

• Recognizing events surrounding the behavior: What tends to affect the behavior, such as changes in the routine and schedule, sleep challenges, or medical needs?

• Identifying predictable events: In what situations are the problem behaviors likely to occur?

• Summarizing the child's play abilities: What successes and d i f f i c u l t i e s does the c h i l d experience in play?

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nzed

Chapter 12 Children's Mental Health

Understanding the function of problem behaviors: What does the child get (or avoid doing) because of the behavior?

• Reflecting on the effectiveness of the problem behavior: W h a t response does the child get? How q u i c k l y ?

The goal of functional assessment is to determine the purpose of the problem- atic behavior, to design interventions to prevent the problem behavior, and to teach

Id appropriate skills or a l t e r n a t i v e behaviors. unctional assessment may be conducted individually by the teacher or with a

the ch A

team that may include family members, behavior specialists, and counselors. Teach- ers conduct and record observations of the child's behavior and keep d a t a to look for patterns of behavior. The team meets to learn about the family's experiences w i t h the child's behavior, to discuss what was observed in the classroom, and to plan appropriate interventions.

This approach is successful in helping teachers and f a m i l i e s work together to p l a n ways to prevent problem behaviors and to increase the effectiveness of man- aging the behaviors in the early childhood setting and home. In the opening case scenario, Meegan may f i n d that the functional assessment process would be a good next step to explore with Heather's f a m i l y to address Heather's behavior concerns.

Mental Health Consultants in Early Childhood Programs

Collaboration with mental health professionals such as behavior specialists, coun- selors' nurses, or physicians provides an i m p o r t a n t benefit to c h i l d r e n who are at risk for or have been diagnosed with a mental health disorder. Consultation sup- ports :eachers and f a m i l i e s when they are not able to understand children's behav- iors a id symptoms and need help managing concerns in the school and home. Together teachers, families, and mental health professionals can usually design an appropriate management plan to address the challenges and assist chik developing coping strategies. This chapter's Progressive Programs &• Practices describes how mental health consultants can be utilized.

Services provided by mental health consultants include conducting observations of children in the classroom and home setting. Consultation is provided to sort out ways to foster healthy social and emotional development and to manage behavior challenges. The consultant is also an important resource for understanding services that may be a v a i l a b l e to the child and f a m i l y in the c o m m u n i t y , such as public or private f a m i l y counseling and behavior management safety net programs that tench parenting skills and provide respite for families as needed. The mental health con- sultant may also play a role in helping children's programs establish an environment that promotes social and emotional development as well as develop policies and procedures to promote children's mental health (Heller et al., 2011).

Many consultants can observe classroom environments and offer recommenda- tions to improve the program. They may also offer training for teachers that address the following topics (Heller et al., 2011):

• Establishing positive relationships with children, families, and other staff. • Creating supportive environments, including schedules/routines and success-

c h i l d r e n in feature

f u • Te

transitions, and designing appropriate rules, idling socioemotional skills to young children.

Developing strategies to address challenging behaviors. i ^y '•iikM Thompson mjhc?fip£ Jlioerty.eflujon 5/9/2017from 143.71.214.211 authorized to use unl 3 the authorized

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Chapter 12 Children's Mental Health

P R O G R E S S I V E P R O G R A M S & P R A C T I C E Promoting Social Emotional Development

By Allison Boothe and Angela Keyes, Tulane University Institute of Infant and Early Childhood Mc-nta* Health

(r The Tulane University Institute of Infant and Early Childhood Mental Health uses a unique

model of early childhood mental health consul- tation (ECMHC). ECMHC is embedded within Louisiana's Qual- ity Rating and Improvement System, Quality Start, which focuses on children's social and emotional development. The approach is designed to assist all children, staff, and families involved in cen- ter-based child care with the goal of achieving healthy behavioral, social, and emotional development for young children.

Through the ECMHC model, mental health consultants pro- vide services across the state, working with individual centers every other week for six months. The mental health consultants strive to form relationships with teachers and directors to assist them in creating supportive environments for young children and building strong teacher-child relationships. With this foundation in place, the mental health consultant works with center staff to design specific interventions for children who exhibit challenging behaviors and provide referrals for families if needed.

Program evaluation has demonstrated that teachers who received the Tulane model of ECMHC believe that they are more efficacious as teachers (Heller et al., 2011). Observation showed that teachers provided increased emotional support for children (e.g., they were more sensitive and showed greater regard for the student's perspective) and increased classroom organization skills (e.g., behavior management) (Heller et al., in press).

The ECMHC model works at two levels: program-wide and child-specific. For example, one center requested ECMHC to assist in the 2-year-old classroom. The teacher, Ms. Jenny, was strug- gling with the aggressive behaviors of three children in her class. The mental health consultant spent time in the classroom and

worked with Ms. Jenny to create visual schedules and visual class rules to help all children in the class know what to expect during the day. The mental health consultant encouraged Ms. jenny to discuss the visual schedule and the three simple rules with the children individually and during small and large group activities to help children to learn and remember the rules. Verbal reinforce- ment was given throughout the day when children followed the rules (e.g., "Wow, Kwan, you used your gentle hands while play- ing with Esme. You should be really proud of yourself!").

After these supports were in place, one child, Jackson, con- tinued to display aggressive behaviors. The mental health con- sultant observed Jackson closely and met with Ms. Jenny and Jackson's parents. Together they created a behavior management plan for school and home. Jackson's family also acted on a refer- ral provided by the mental health consultant to help Jackson get a behavioral evaluation.

Teachers who have worked with mental health consultants in their classrooms using ttie Tulane model have said:

"It is always nice to have a fresh pair of eyes to see things that I may have missed ... just to see the same situation in a different perspective ... the idea that all situations have a solution. You just have to figure it out!"

"I had a challenging child in my class, and sne and I worked together to find solutions to help him. She was very encouraging to me. She taught me to praise good pehavior and other children will follow."

Source: HeHer, S !>., Boothe, A., Keyes, A., Nagle, G., Side:1, M , Si Rice. Jj. (2011) iT.piernenurjon, of a mentei health consultation model and ts impact on party childhood teacher?' efficacy and competence. Mant Mental Health Journal, 32, 143-164. doi:10.1002/imhi.20289

CHECK YOUR

UNDERSTANDING 12.4 v

Click here to check your

understanding of mental

health disorders in children

and the teaching strategies

for those children.

Providing mental health services in the early childhood setting is a prevention effort that benefits all children who are enrolled. In this way, early childhood teach- ers and their programs contribute to public health by ensuring that children's social and emotional needs are recognized and addressed.

Unfortunately, few early childhood teachers have access to mental health con- sultants and not all schools have counselors or behavior specialists on s t a f f . Commu- nity resources may be available to provide some assistance. Local early intervention services for children with special developmental needs or c o m m u n i t y h e a l t h ser- vices may offer some supports.

P u r s u i n g professional development t r a i n i n g related to children's mental! health and advocating for resources to use in accessing occasional mental health C o n s u l - tations are other i m p o r t a n t ways teachers build skills and raise awareness of the importance of children's mental health. Teachers are in a good position to engage in advocacy efforts that bring attention to the need for mental health services for

., young c h i l d r e n . n fl-orizsd is , .

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Chapter 12 Children's Mental Health

SUMMARY

Children's mental h e a l t h refers to children's capacities to manage and express appropriate emotional responses and behaviors, to form close relationships, ar^d to explore and learn. Children who are supported to develop these capabil- ities are able to adjust successfully to new situations and build positive future IV ationships.

• There are key skills in c h i l d h o o d t h a t promote s o c i a l and emotional well- ness: forming healthy relationships and developing self-concept, self-efficacy, se f - r e g u l a t i o n , and resilience. Teachers can promote these s k i l l s by creating supportive e n v i r o n m e n t s , establishing caring relationships, and reali/.ing the importance of play.

• Teachers can better manage mental health problems by understanding preva- lence, consequences, c u l t u r a l influences, and relationship to physical health and by recognizing atypical behaviors in the classroom.

• Mental health disorders in childhood include behavioral, anxiety, and mood disorders. The teacher's role is a critical component in diagnosis and manage- ment of these conditions.

/

Chapter Quiz

3 C l i c k here to check your understanding of Chapter 12, Children's Mental H e a l t h .

Discussion Starters

1. T h i n k of a c h i l d of any age you know or have worked w i t h who e x h i b i t e d d i f f i c u l t beiaviors. Discuss any risk factors the child had, such as l i v i n g in poverty or in a sin- gle-parent household? Discuss any specific w a r n i n g signs?

2. Consider a child in the early childhood setting who has been exposed to a s i g n i f i c a n t a m o u n t of violence and is d i s p l a y i n g severe aggression in the classroom. Can you apply the principles of inclusion described in the chapter? How do you feel about including these children in the classroom? Describe some advantages and disadvan- tages to inclusion.

3. Based on what you have read about risk factors that contribute to poor mental h e a l t h in children, what national policies contribute to these risk factors? What national pol- icies help alleviate the stress of these factors on children? What services available in y o u r community help families who are atrisk?

Practice Points

1. Teachers have m a n y opportunities in the classroom to promote social and emotional development by establishing h e a l t h y relationships and promoting h e a l t h y play activ- ities. How can teachers engage f a m i l i e s in promoting healthy social and emotional development? by MikKi Thomp»on (nthompson21@llbe?1y sdu) on 5/9^20 i 1 tr;m 143 ,'\1 authorized to use ur-'i 3/16/2

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