The first step toward ensuring that children receive the mental health services they need—and that are equal to all—is to perform more research that is generalizable to them and sensitive to diverse cultural groups. This goes hand in hand with establishing the use of valid and reliable screening measures for emotional/behavioral disorders appropriate to preschool-age children. Second, we must establish minimum levels of functional impairment with respect to duration and domains, and report prevalences in ranges. These steps would lead to a more appropriate, updated standard definition for emotional/behavioral disorders in very young children. A “Standard Developmental Risk Profile” would help provide early diagnosis for children at-risk. We must remove barriers to treatment, and last but not least, create a new, universal approach for supports and services for children and their families—a new “Comprehensive Early Childhood Mental Health Plan.”
Expand research and establish the use of valid and reliable screening measures
Expanded funding from non-profit, state, and federal agencies would enable more research that is data-sensitive to all cultural groups and generalizable to states and the U.S. This would be a huge step toward ensuring proper supports and services for preschool children with emotional/behavioral disorders and their families based on scientific relevance. System-wide problems, including the lack of appropriate training for pediatricians and development of effective mental health services for young children, must all be addressed. Until this subject is well studied, some of the concerns expressed about screening programs must be taken into account.35
These include the negative effects of labeling a child. Establishing standard, valid, and reliable screening measures for emotional/behavioral disturbances applicable to preschool children is key.
The use of a standardized, fully structured, self-administered epidemiological questionnaire for families and standardized screening measures for families and teachers/caregivers should be implemented throughout the U.S. These questionnaires can be an ongoing method to collect data for a much-needed database. The expense could be minimized by using a low-cost data collection method such as paper and pencil self administration (perhaps in the form of mail questionnaires), or a questionnaire administered in public health clinics, preschools, daycares, and private pediatricians' offices.
These standardized screening measures could be given to the parents/guardians, teachers/caregivers, and health care workers as a means to identify and treat the children at-risk and/or with emotional/behavioral problems earlier. These screening measures should be specifically for the preschool population.
Because most parents of preschoolers with emotional/behavior problems do seek assistance, screening whole communities, linking programs to preschools, or advertising statewide may increase participation in prevention or intervention programs for the future.
Substantial evidence indicates the benefits of early provision of interventions to prevent behavior problems and poor school performance.11,36
Accurate assessments of behavioral/emotional problems in preschool children is an important goal. The observation that untreated psychiatric problems in preschoolers often tend to persist at least into the grade school years emphasizes the great importance of accurate assessment and early identification. The evaluation of emotional/behavioral problems in preschoolers has traditionally relied on parent, teacher, or observer reports.37,38
It is important that future screening measures use multiple sources.
Multiple settings should also be considered because of the impact on the development of problem behaviors. The initial assessments will help identify important risk factors and protective factors that will lead us to the proper program of supports and services.
Define levels of impairment in ranges
There is little consensus on how minimum functional impairment should be defined or measured. Children must be seen in the context of their social environments—that is their family, their peer group, and their larger physical and cultural surroundings. According to the 1999 Surgeon General's report on mental health, “The developmental perspective helps us to understand how estimated prevalence rates for mental disorders in children vary as a function of the degree of impairment that a child experiences in association with specific symptom patterns. The science of mental health in children is a complex mix of development and the study of discrete conditions or disorders.”1
Both of these perspectives are useful. “Each alone has its limitations, but together they constitute a more fully informed approach that spans mental health and illness and allows one to design developmentally informed strategies for prevention and treatment.”1
In the absence of any “standard” that could be used as a basis for establishing a cut-off point for minimum functional limitation, and in the absence of any social validation process that has established a consensus on the threshold, data should be presented for many levels of impairment. This has the benefit of providing additional information to planners and policy makers, and to stimulate further discussion and research to establish an appropriate threshold. It has the disadvantage of possibly overestimating the occurrence of a serious health problem. A “standard” for an established cut-off point for minimum functional limitation must be approved; then and only then will we be all on the same page.
Report prevalence in ranges
Prevalence should be expressed in ranges, allowing treatment for children before they are “labeled” as emotionally disturbed. This would also allow for ranges of minimum functional limitation, rather then just one cut-off point. Expressing prevalences in ranges associated with minimum functional limitations would also address the need for variations for different age groups, racial and ethnic groups, genders, and socioeconomic groups. Based on our analysis of the findings from the studies reviewed, the sampling, measurement, overall methodological considerations, and levels of minimum functional impairment, we estimate the prevalence of emotional/behavioral disturbance in children 0–5 years of age is in the range of 9.5% to 14.2%.
Update the standard definition
The broad variation in criteria and methodology of the measures revealed in our literature search also makes it clear that those prevalence rates are not generalizable to individual states (such as my home state of Louisiana) and/or the United States. A clear updated standard might be to define an emotional/behavioral problem as: “Any behavior or range of behaviors listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as a symptom of emotional/behavioral disorder or a problem description that is consistent with these symptoms, such as aggression at home and/or school, etc. for a shorter duration, and not in all domains (environments) and a specific range of minimum functional limitations.”
Bennett et al. stated, “However, through review of the scientific literature, there still needs to be further investigation to clarify the predictive validity of externalizing behavior symptoms in nonclinical populations for their usefulness as a risk assessment method. From a developmental perspective, substantial stability of externalizing behavior symptoms exists over time. However, from the perspective of prevention, significant levels of misclassification will occur when externalizing behavior symptoms are used to designate high risk status under the low prevalence conditions of a normal population.”39
I could not have stated this any clearer, which is why I strongly concur with his recommendation.
Despite the shortcomings in the conceptualization and measurement of minimum functional impairment, there is a relationship between emotional disturbance and use of mental health services. An updated standard definition would be useful to establish severity levels in determining the service implications of diagnoses. An updated standard definition would also allow an earlier and proper diagnosis of more of these children earlier in their lives, so they could also be treated earlier.
Given the vast differences in reporting of children with emotional/behavioral disorders and the lack of early diagnosis, a standard methodology for establishing prevalence with a “standard definition” should be used when planning programs for these children.
Create a standard “Developmental At-Risk Profile”
An established standard “Developmental At-Risk Profile” is in order to identify these children. The Figure shows a suggested developmental at-risk profile that could be implemented throughout the United States.
This profile represents the interaction of all the demographic factors. But one could ask, are these independent risk factors for emotional/behavioral problems? Only poverty has been identified as a powerful risk factor on its own, so much so that an algorithm for developing some state prevalence rate estimates includes an adjustment according to the state median income levels.26
However, given the evidence that few risk factors are disorder-specific, a broad-based approach to risk reduction is more appropriate than an approach based on specific risk factors.
A major challenge in psychiatric epidemiology is that, unlike chronic physical illnesses such as cancer and heart disease—which can be clearly linked to narrow risk factors such as diet and smoking—the onset of mental illness is related much more strongly to broad measures of environmental adversity. These broad, nonspecific risk factors are interrelated and usually combined. Again, given the evidence that few risk factors are disorder-specific, a broad-based approach should be implemented for future strategies. The focus of future studies should be areas of high child poverty rates, children exposed to stressful life experiences, aid to single parents with dependent children, and social support and coping mechanisms.
Remove barriers to treatment
Studies of the determinants of help-seeking show that financial barriers are significant obstacles to treatment, and that treatment rates increase when these barriers are removed.40
We must find financial sources to assist our citizens in receiving much-needed professional help. This is especially important in states like Louisiana, where the state funding situation is extremely grave.
We must also address the common perception that mental health problems will go away by themselves. Many people would rather deal with the problem themselves than pursue treatment or support. Many people believe that treatment will not be effective. These findings imply the perceived stigma related to mental illness. This alone is reason enough to begin a culturally diverse educational awareness campaign to educate our citizens about mental health diagnoses. It also highlights the need for community needs assessments—through focus groups in Louisiana and throughout the United States—to identify specific populations' perceptions of mental health as related to early childhood mental disorders. Public awareness/education campaigns will be critical in these efforts. Targeted secondary interventions for these populations should be used for two major reasons: first, the realization that many mental disorders begin at an early age; and second, the need to focus delivery of the interventions in high-risk segments of the population. Providing coping strategies for high-risk populations would be extremely beneficial. Other ways to reach these populations include using standardized conceptual models to study the help-seeking process that highlight the importance of health beliefs, including the perceived need for treatment, barriers to seeking treatment, and the perceived efficacy of treatment. These models will be useful in comprehending and altering the process in the future.
We must also develop a strategy for the delivery of mental health supports and services to children 0–5 years of age and their families. These services should assist in improving access to health care for families and offer parent training programs and resources. This multidimensional model should also address the need for education for physicians and health care workers on the importance of early identification of emotional/behavioral disorders. These model interventions should be community based, and located in high-poverty areas with high numbers of at-risk children and families, as identified by appropriate screening measures.
Another type of barrier that must be addressed is the need for regular and reliable estimates of the incidence/prevalence of child abuse and neglect based on sample surveys rather than administrative records. These children are at extreme risk for emotional/behavioral disorders, and must be identified early and correctly. Child abuse/neglect is another risk that alone can produce emotional/behavioral disorders in children. We cannot depend on administrative records to count these children, because these records report only cases that are substantiated; it is likely that official records of child abuse and neglect underestimate the magnitude of this problem. Estimates from sample surveys potentially provide more accurate information of child abuse and neglect; however, we must consider how to effectively elicit this sensitive information. We must also consider whether there is an ethical responsibility to report abuse or neglect discovered in the course of research.
Create and implement a new “Early Childhood Mental Health Plan”
If implemented, our recommendations will lead to continued research and will form the basis for creation and implementation of future interventions and the adoption of a new comprehensive Early Childhood Mental Health Plan. This new approach to the way Louisiana and the U.S. treats its very young is important to our future and will allow our children to contribute to and live a “normal” existence in our state and nation.