Module 4: Promoting Mental Health in Early Childhood

Developmental Surveillance in Early Childhood

Developmental surveillance continues throughout early childhood as providers and families observe the toddler's abilities and skills over time. The process is a collaborative one as both the provider and the family note the toddler's progress and share concerns. At each visit, the concerns of the family are the highest priority. Providers should listen carefully to parental concerns and observations.

Developmental Surveillance Components

Providers can integrate developmental surveillance into each early childhood visit by:

  • Asking parents if they have any specific concerns about their toddler's development, learning, or behavior
  • Obtaining or updating a developmental history
  • Observing the interactions between parents and child
  • Identifying risk and protective factors
  • Screening with a validated developmental screening tool at 18 and 30 months and any other time concerns are raised by parents or others involved in the care of the child.
  • Screening for autism with an autism-specific tool at 18 and 24 months and any time a parent raises concern
  • Sharing observations and concerns with other relevant professionals, as needed
  • Documenting both the process and the findings

Mental Health Risk Factors in Early Childhood

As part of developmental surveillance, providers should assess for risk factors for mental health problems in early childhood, including:

Child Factors

  • Serious and chronic medical problems
  • Lack of emotional attachment
  • Cognitive disabilities
  • Communication difficulties
  • Impulsivity
  • Aggression
  • Poor social skills

Family Factors

  • Parental mental/emotional illness
  • Maternal depression or social isolation
  • Parental substance abuse
  • Lack of warmth and affection
  • Inconsistent, harsh or unclear discipline
  • Unreasonalbe developmental and behavioral expectations
  • Poor supervision or monitoring
  • Failure to adapt to changing needs

Environmental Factors

  • Poverty or homelessness
  • Family stress, including separation and divorce
  • Exposure to domestic violence or early trauma
  • Child abuse and neglect
  • Persistent fear and stress
  • Lack of stimulation

Protective Mental Health Factors in Early Childhood

Providers can promote and advocate for the following strengths, skills, and assets that foster healthy mental development in early childhood:

Child Factors

  • Secure emotional attachments
  • Effective communication
  • Increasing self-regulation
  • Social competence
  • Self-awareness
  • Emerging independence
  • Self confidence
  • Coping skills

Family Factors

  • Family harmony
  • Secure, stable family
  • Loving, warm relationships
  • Appropriate structure and routines
  • Reasonable developmental and behavioral expectations

Environmental Factors

  • Positive learning environment
  • Quality child care
  • Opportunities to interact with other children
  • Economic security
  • Good housing
  • Healthy and safe neighborhood
  • Access to support services

Developmental Surveillance at Specific Visits

Surveillance occurs at each visit and takes place over time to allow for assessment of the child's achievements and developmental milestones:

12 months

Social-emotional

  • Plays interactive games (“peek-a-boo,” “pat-a-cake”)
  • Imitates activities
  • Hands you a book when he wants to hear a story
  • Waves “bye-bye”
  • Has a strong attachment with parent or significant caregiver
  • Shows distress on separation from parent

Communicative

  • Demonstrates prodeclarative pointing (points to a desired object and watches to see whether the parent sees it)
  • Imitates vocalizations and sounds
  • Speaks 1 to 2 words
  • Jabbers with inflections of normal speech

Cognitive

  • Follows simple directions
  • Identifies persons upon request (e.g., “Where is ___?”)

15 months

Social-Emotional

  • Listens to a story
  • Imitates activities
  • May help in the house

Communicative

  • Indicates what he wants by pulling, pointing, or grunting
  • Brings objects over to show you
  • Hands you a book when he wants to hear a story
  • Says 2 to 3 words (not Dada/Mama) with meaning

Cognitive

  • Understands and follows simple commands
  • Scribbles

18 Months

Social-Emotional

  • Is interactive or withdrawn; friendly or aggressive (eg, hitting, biting)
  • Laughs in response to others
  • Explores alone but with parent in close proximity
  • Is spontaneous with affection
  • Helps in house

Communicative

  • Vocalizes and gestures; speaks 6 words
  • Points to indicate to someone else what he wants

Cognitive

  • Points to 1 body part
  • Follows simple instructions without gestured cues (”sit down”)
  • Shows interest in a doll or stuffed animal by hugging it or pretend feeding
  • Knows the names of his favorite books

2 Years

Social-Emotional

  • Imitates adults
  • Increases pretend play (rocking, feeding, or putting baby doll to bed)
  • Plays alongside other children (parallel play)
  • Refers to self more often as “I” or “me”
  • May have established a special attachment to a transitional object

Communicative

  • Has vocabulary of at least 50 words
  • Uses 2-word phrases
  • Asks parent to read a book

Cognitive

  • Follows 2-step commands
  • Names one picture, such as a cat, horse, bird, dog, or man
  • Completes sentences and rhymes in familiar books
  • Corrects you if you change a word in a book he knows
  • In response to, “Where is _____?”, points to object or animal in a book

2 1/2 Years

Social-Emotional

  • Imaginary play, such as with dolls and toys, is increasing
  • Play is starting to include other children to an increasing degree, such as play tea parties or chase games
  • Has fears about unexplained changes in his physical environment and unexpected events (common in children of this age)

Communicative

  • Uses short phrases of 3 to 4 words
  • Is understandable to others 50% of the time

Cognitive

  • Knows the correct action for a selected animal or person (eg, cat meows, horse gallops, bird flies, dog barks, man talks)
  • Has friends
  • Points to 6 body parts

3 Years

Social-Emotional

  • Has self-care skills (eg, self-feeding and self-dressing to the extent this is desired and permitted within individual family and cultural norms)
  • Imaginative play is becoming more elaborate, with specific themes or story lines demonstrated
  • Enjoys interactive play

Communicative

  • Carries on a conversation with 2 to 3 sentences spoken together
  • Is understandable to others 75% of the time
  • Names a friend

Cognitive

  • Knows the name of and the use of a cup, ball, spoon, and crayon
  • Identifies self as a girl or a boy

4 Years

Social-Emotional

  • Describes features of himself, including gender, age, interests, and strengths
  • Is responsive or withdrawn
  • Is friendly or hostile/aggressive
  • Is cooperative or defiant
  • Acts appropriately for the community’s or family’s cultural values
  • Plays with favorite toys
  • Listens to stories
  • Engages in fantasy play

Communicative

  • Gives first and last name
  • Sings a song or says a poem from memory
  • Knows what to do if cold, tired, or hungry
  • Is clearly understandable with most speech efforts

Cognitive

  • Names 4 colors
  • Is aware of gender (of self and others)
  • Plays board/card games
  • Draws a person with 3 parts
  • Tells you what he thinks is going to happen next in a book
 

Source

For areas of developmental surveillance: American Academy of Pediatrics, Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition.

Copyright Georgetown University Georgtown University Early Childhood