Improving infant mental health outcomes in early learning settings for children who have experienced trauma

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The Australian Mental Health Productivity Commission report recommended “strengthening skills and workforce of early childhood educators to meet the needs of children’s 0-3 social and emotional development” (Australian Mental Health Productivity Report, 2020, p. 11). Furthermore, the National Mental Health Commission has been tasked with developing this strategy as part of the Australian Government’s long-term National Health Plan. This plan is the first of its kind, with a focus on children from birth to 12 years of age. In part, these recommendations are to focus on supports that may be required for educators. They list three main objectives: educator well-being, targeted responses for children, and well-resourced and skilled educators (National Children’s Mental Health and Wellbeing Strategy, 2021, p. 10).

This article will:

  1. Describe an innovative evaluated programme, Intensive Emotional Support Plans (IESP), developed by Goodstart Early Learning (Goodstart), Australia. Goodstart is Australia’s largest not-for-profit early learning provider. Goodstart has long had an inclusive policy which supports children who have experienced significant childhood trauma. IESPs, help support inclusion by attending to individual children’s traumatic presentations, supporting the centre team, and upskilling and strengthening educators’ skills in trauma-informed practice.
  2. Present a summary of a recent evaluation of the IESP approach undertaken by the University of Adelaide, and
  3. Illustrate the practice implications of the IESP, throughout the paper, via a case study profile of Henry, a three-year old boy and Claire, Henry’s key educator at his early learning centre. Please note, all names and some details have been changed to protect the identity of the children, their families, and the staff.

Introducing Henry, his family, and Claire


Henry is a three-year-old boy, the eldest of two. He has attended his local Goodstart centre five days a week since he was one. Henry is at the top of the percentile chart for height and weight. He is usually quiet in nature, but in the last six months he has had extreme aggressive outbursts, often resulting in physical injuries to educators and children. Due to Henry’s unpredictable behaviours numerous children and educators are wary of him and tend to avoid engaging with him.

Henry’s parents

Henry’s parents met while homeless when they were teenagers. Henry’s mother has a history of mental illness and left her partner unexpectedly for one year, when Henry was 12 months old. Before leaving and after her return there was significant domestic violence in the family, perpetrated by Henry’s father.

Henry’s father has a history of mental illness, drug abuse and criminal activities. It is important to note that he has been on parole and drug free for the past year. Henry’s paternal grandparents have cared for both children during times of parental absence.


Claire is Henry’s key educator. She has formed a caring relationship with him, and Henry tends to follow her wherever she goes.

The Intensive Emotional Support Plan (IESP) Design

For early learning educators to provide emotional support to such high-risk children, they must be well supported themselves (Dolby, Ebert, & Watson, 2008). The IESP was designed in response to this need and includes the children, their families, and their educators. To date, over 185 children have been successfully supported in this approach.

This plan provides an additional educator for a 12-week period to support the inclusion of a child presenting with withdrawal or volatile trauma presentations. The additional educator provides relationship based, intensive emotional support and is not counted in staffing ratios, allowing them to be always available for the child. This educator’s first objective is to build a secure relationship with the child, narrating and helping make sense of the environment when calm and co-regulating with the child when in a heightened or aroused state. This educator also supports the child to negotiate relationships with other children. They help the child to identify, when possible, their own body’s warning signals for distress, such as a fast heartbeat, and role model, and support the child to learn breathing and mindfulness techniques.

Over the 12 weeks, the educator’s goal is to transfer a sense of safety and containment to all other educators, sharing the strategies learned that have helped the child in heightened states. These strategies are also shared with the child’s parent/carer. To carry out this role, it is essential for the selected educator to have strong empathic relationship skills and a sound knowledge in educating and caring for children with ongoing high needs. Although there is one nominated educator working with the child intensively, for this plan to be successful, those factors which contribute to the child becoming emotionally dysregulated, must be understood and implemented by the whole centre team.

A reflective journal is developed for the child and family, with pictures of interactions (both successful and challenging) added for the child to reflect on with the educator when in a calm state. The educator reads the journal as a story and talks about how the child coped during the tricky times.

The IESP program is overseen by a multidisciplinary team of child and family practitioners, who have expertise in Infant Mental Health, Circle of Security (Zanetti et al., 2011) and trauma-informed practice. The child and family practitioners offer weekly support to the educator and coordinate meetings with parents/carers and involved external agencies. Currently there are fourteen child and family practitioners working across Australia.

Eligibility for IESP

As part of the social inclusion team, Goodstart Early Learning has a central Help Desk that all centres can contact when experiencing barriers to inclusion. The Helpdesk is run by three support workers who have expertise in Early Childhood Education and Care (ECEC) and inclusion. When a request for support is received, such as the one from the centre where Henry attends, the Helpdesk will connect with the centre to gather details such as child protection concerns (current or historical), family history, the nature of the centre’s relationship with the family, behaviour concerns, relevant diagnoses, external services involved, and the level of support being requested.

If there is child protection history and the child is at risk of exclusion, the Helpdesk will refer onto the National Manager of the Child and Family Service for review and eligibility for the IESP program. The approval and prioritisation criteria are based on each individual request and guided by evidence of current or historical trauma and the child’s presentation, “how long can the child wait?”

All centre’s that submit a request are offered a level of support by the Social Inclusion Co-ordinator or a child and family practitioner, which could include foundational support via tele-health, face-to-face visits, and when approved, the IESP.

When approved for the IESP support, the centre is allocated a child and family practitioner and an extra out-of-ratio educator is funded to implement a 12-week support plan. The length of the plan is dictated by the available budget with the possibility of extension if necessary. Currently the Australian government Inclusion Support Programme (ISP), only provides funding for an out-of-ratio educator for room support only.

It was identified that room support alone does not allow the gradient individual relationship component of the IESP to develop, as the educator has competing priorities with other high needs children in the room and daily routines. Due to these restrictions, Goodstart Early Learning, self-funds the programme, at an approximate cost of $12,000 per child.

Henry, Claire, and IESP: The beginning

One afternoon Claire was sitting with Henry, closely together in a quiet reading area. They were seated on cushions on the floor.

Over the other side of the room, a child ran past, slipped over and fell hard onto the floor. Claire responded quickly by getting up to help. She turned to Henry and put her hand out and said “Henry, wait here. I’ll be back”.

As Claire was getting up, Henry launched at her putting his hands around her throat, screaming, and kicking her. It took two other educators to remove him from Claire. Claire was injured and needed medical attention for multiple deep scratches and bruising on her neck.

After this incident, Claire requested not to work in the room Henry was in because now she was afraid of him.

Henry’s aggressive escalations increased from occasionally to multiple incidents every day. Educators and parents of children in the room began advocating strongly for his exclusion from the centre.

As Goodstart’s policy is to work with and for these very vulnerable children, our response was not exclusion but to ask, “How can we support Henry’s inclusion, while supporting our educators and every child’s education and wellbeing?”

The role of the child and family practitioner

In the week prior to the educator starting in the room with the child, the centre team receives training from the child and family practitioner. The training package includes basic understanding of the impact of trauma on attachment and normal brain development, the importance of educator self-care and general strategies to support on-floor practice and the wellbeing of the educators. The training also includes the specific child’s presentation, so that educators understand the “why” behind the child’s behaviours, such as Henry’s “fight” response when Claire suddenly got up and gestured with her hand near his face. The development of each plan is tailored to each individual child’s trauma presentations, using the reflective journal.

Henry, Claire, his family life, new beginnings

Soon after the incident with Claire, Henry’s father was incarcerated for multiple crimes and his mother’s drug use increased. Henry was placed in emergency foster care for two months and then placed in the care of his paternal grandmother. Over these two months Henry was away from the centre as the foster care placement was a significant distance from the centre.

Henry’s paternal grandmother reached out to the centre to re-enrol him when he was placed back into her care. She disclosed Henry was having significant volatile outbursts at home and she was struggling to care for him. Due to his presentations at home and past presentations at the centre, he was approved an IESP to assist his transition back.

Claire asked if she could be his support educator, as she felt he must have been so scared when he was removed from his home.

Once a week the child and family practitioner meet with the educator to provide practice guidance and support. As Henry’s predicament illustrates, there is often a significant rupture in all relationships in the centre. The role of the child and family practitioner initially, is to function as a secure base for the education team to work through the relational challenges. It is only when the education team experiences being held in mind, that they can begin to see the child, and not just the behaviour.

After the training is delivered, the educator is asked to observe the child for the first week, to gain an understanding of their developmental age in social, emotional, and relational areas. The educator is to observe the child’s interactions from a strength-based approach. When children suffer trauma, they miss critical developmental stages. It was identified that Henry’s emotional age was much younger than 3 years, so his ability to co-regulate, self-regulate, and to be able to engage with peers, was significantly delayed. The initial practices the educator implements with the child, is based on the child’s developmental rather than chronological age.

The Marte Meo framework (Aartes, 2008) is used to support challenging behaviours from a developmental perspective. Behaviours are viewed as an opportunity for development rather than a ‘problem’ to be fixed. With permission, the educator videos the child at different times during the day. This video is then used to help the educator reflect on and enter the child’s world. The educator documents any delightful moments, such as the child having success engaging in an activity or playing with a peer, the child’s areas of strength, and capacity to co/self-regulate. For example, how long can the child tolerate relational interactions and do they seek support from educators?

The educator also documents the child’s “high risk” times. The purpose of this is to show the child’s strengths in difficult situations. In the one-on-one moments, the educator allows the child to choose the learning experience and delights with them in even the smallest of successes (Muir et al., 2006). This supports the educator and child to discover together a new way of relating to each other.

Claire’s first week of supervision

During the initial week of supervision, Claire noted there had been many incidents of biting and kicking. She was frustrated as she could not identify triggers for these escalations and her colleagues in the room were starting to ask her why she wasn’t doing anything about Henry’s behaviour.

Claire wondered aloud if Henry even liked her anymore. She was disheartened as she had tried so hard to become Henry’s secure base again.

Claire brought some video footage of Henry playing during inside/outside activities to supervision. While reviewing the footage the supervisor suggested that they “just watch Henry and see what he tells us about his world”.

Henry is initially sitting by himself; he looks over to three children playing with blocks. Henry then walks over to the three children and stands behind them, with his head down. The other children finish their play and move away not noticing Henry. Henry still with his eyes down, briefly glances across the room to Claire and then follows the children to the next activity. Once again, he stands behind them. Another educator walks over and Henry silently moves next to her and glances at the children. The educator does not notice Henry and walks away.

Claire suddenly turned to the supervisor and said, “I wonder why he just stands there and doesn’t say anything?”  The supervisor wonders with Claire.

Henry then walks over to another group of children, with his head down still and glances again over to Claire, briefly.

Claire stopped the review video and looked at the supervisor and said, “I think he wanted me to help him? Maybe Henry does see me as his secure base?”

At the end of the review Claire reflected that it must be incredibly frustrating for Henry to want to enter play and relationships with other children and seek help from educators when no one ‘sees’ him and he doesn’t know how to. Claire then said she feels sad that she hadn’t noticed Henry looking to her for help. The supervisor held the moment allowing Claire to stay with her thoughts. Claire then said, “but it’s nice that Henry does see me as his secure base. I am going to help him learn how to enter into play. We can start with supporting Henry to say “hello” when he walks up to other children”.

This moment is a pivotal part to the success of the IESP. By supporting Henry to connect back into the early learning environment, Claire is giving Henry the experience of being seen, “When I look, I am seen, so I exist. I can now afford to look and see. I now look creatively and what I apperceive I also perceive.” (Winnicott, 1971, p. 3).

Team around the child

Another important component of the IESP approach is the communication with the parent/carer and with external stakeholders. The educator is supported to initiate contact with the child’s parent/carer, to explain the plan and share the observations made. The educator develops a communication book for the parent/carer to continue sharing observations. A book with photos taken of the child’s day is also developed for the educator and child to look through. The purpose of this is to share with the child, in their calm times, their world in the early learning environment. When a referral for an IESP occurs, often there are multiple services involved in the family and child’s life. It is also common that, like for Henry, some sort of crisis is occurring, like removal from parental care, placement breakdown or change, domestic violence, or parental mental illness.

Throughout the plan at least three partnership meetings are held. This process ensures all information, such as who is the child’s carer, will access visits occur, are there allied health professionals involved and is anyone keeping the child’s current state of wellbeing in mind.

Holding Henry in mind

Over the next 5 weeks, Claire experienced great success in supporting Henry to play, and he would say hello to anyone that walked past. Each day they started with bubble or balloon blowing, followed by story time, to provide Henry with predictability that supported him to transition into the centre.

In the calm times Claire asked Henry to count how fast his heart was going, then when running outside, she would ask him to count again.

Claire then introduced taking big slow breaths, to see if that slowed his heart. When she noticed him starting to get frustrated, she would offer him bubbles to blow to slow his heart.

By week 5, Henry was having only one or two escalations a week and was starting to spend time with other educators.

Claire shared with his grandmother the strategies that were working. Grandma reported that when she became frustrated with him, Henry offered her bubbles to blow.

It was all going so well, then …

Around week 6, Henry’s behaviours started to escalate again. He had days where he was very withdrawn, and days he was highly emotive. Claire couldn’t understand what had changed for Henry. Grandma reported she was not seeing these behaviours at home. Henry’s outbursts escalated to the point he smashed a window in the centre, almost hurting a few children. He began growling at anyone who came near him. The centre held serious concerns for Henry’s mental wellbeing.

A partnership meeting with Grandma and the child protection agency was held

During the meeting the child and family practitioner asked if there been any significant changes in Henry’s life. Grandma stated there had been no changes at home, adding that court appointed access visits to his father in prison and to his mother, who was now residing in a drug rehabilitation service had started two weeks prior. The access visits to the prison occurred in the morning and Henry would be dropped off at the centre afterwards.

The Child Protection agency then reported that only one visit with Dad occurred, as Dad refused to see Henry the second time, leaving Henry sitting in the visitor’s room at the prison. The worker reported Henry had started screaming as they drove up to the prison gate for the second visit. As they were court appointed, the visits were compulsory and couldn’t be changed until the next court date. 

Access visits with Mum were more successful, but they reported Henry was often very sad leaving her.

Connecting Henry’s behaviour with his day-to day experiences

On review, the dates of the aggressive escalations occurred the day before and following the visits to Dad with the biggest escalation occurring on the visit where Dad didn’t arrive. He was most withdrawn after visits with Mum.

It was very evident Henry was not coping emotionally with access visits and needed extra support. The child protection agency agreed to advocate to stop access visits at the prison, with a possible video call instead.  Claire spent more one-on-one time with Henry after these access visits, while continuing to encourage him to connect with other educators.

By week 10, Henry had settled again in the centre, spending most of his time in the planned program for all children, only checking in with Claire when tired or overwhelmed.

By the end of the plan, Henry had no escalations and on one occasion when a peer threw a toy at him, he walked over and handed his peer his bubbles and said, “you need to do big blows”. Then he went to tell Claire that his friend needed her. 

IESP Evaluation summary

The University of Adelaide evaluation in 2019, found the IESP approach to be a very robust, effective, evidenced-based intervention for reducing trauma based aggressive and withdrawal behaviours in children attending ECEC (Karpetis, 2020).

The study found 80% of children participating in the IESP were averaging four daily aggressive escalations before commencing the program; by the final week, the figure was 5%. There was also a similar reduction of withdrawal instances, with 90% of children presenting with four daily escalations before beginning the IESP and no withdrawals in the final week. The children were also more capable of playing with peers.

The evaluators also observed that children increased their ability to name their emotions, improved their language skills, had increased capacity to participate in learning experiences, demonstrated more empathy toward peers and approached the out-of-ratio educator as an attachment figure. The gains appeared higher for the children of younger age as well as for those whose family collaborated in the implementation of the IESP.

In brief, the intervention was found to be highly successful in preventing the exclusion of children in ECEC. The study also found that over the course of the intensive, educators developed their emotional understanding of the child, were protective and caring towards the child, collaborated with the child’s family, and grew in confidence in their practice. The evaluators found that the effective structural elements of the IESP included:

  1. Employment of out-of-ratio educators,
  2. Trauma-informed and attachment-based training of the out-of-ratio educators, and
  3. Attachment-based trauma-informed supervision provided weekly to the out-of-ratio educator.


Henry and Claire are representative of many children and educators in our early learning settings. Over the years a question debated in the infant mental health literature has been “under what circumstance do children thrive or suffer in early childhood care?” (Hungerford, 2005). The IESP model creates a unique opportunity for infants who have experienced trauma to thrive within a secure and nurturing early learning environment.


Aarts, M. (2008). Marte Meo, Basic Manual (2nd ed.). Eindhoven: Aarts Productions.

Dolby, R., Ebert, C., & Watson, S. (2008). Childcare: A “holding environment” supporting infants and their parents with mental illness and emotional difficulties. In: A. Sved-Williams & V. Cowling (Eds.), Infants of parents with mental illness developmental, clinical, cultural and personal perspectives (pp. 249-261). Bowen Hills, QLD: Australian Academic Press.

Hungerford, A., Brownnell, C., Campbell, S., (2005). Child care in Infancy: A transactional perspective. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (p519-532). New York: The Guilford Press.

Karpetis, G. (2020) Evaluation of the effectiveness of the Goodstart Early Learning Intensive Emotional Support Plans. Adelaide University, Australia.

Muir, E., Lojkasek, M., Cohen, N. (2006). Watch Wait and Wonder: An infant-led approach to infant psychotherapy. The Signal, 14:2.

Productivity Commission 2020, Mental Health Report no. 95, Canberra

The National Children’s Mental Health and Wellbeing Strategy, 2021

Winnicott, D.W. (1971). Playing and Reality. London: Tavistock Publications.

Zanetti, C. A., Powell, B., Cooper, G., & Hoffman, K. (2011). The circle of security intervention: Using the therapeutic relationship to ameliorate attachment security in disorganized dyads. In J. Solomon & C. George (Eds.), Disorganized attachment and caregiving (pp. 318–342). New York: The Guilford Press.


O’Donnell, Alma-Jane,
Goodstart Early Learning, Australia

Alma-Jane O’Donnell is the National Manager of the Child and Family Service for Goodstart Early Learning. Alma is a Perinatal and Infant Mental Health Specialist, with a master’s degree in Perinatal & Infant Mental Health. Alma has over 30 years’ experience working nationally and internationally with in early intervention research, project development, IMH clinical supervision, while also contributing to the national roll-out of trauma informed programs, policies, and procedures within Goodstart Early Learning.