…It makes sense to begin with an awareness that every human being incorporates the history of his or her relations with others – a history that is at once social and personal, physical and psychological….
Christina Toren, 2008
Currently, there are escalating crises across multiple domains related to the care and support of infants, children, and families (Baer et al, 2017; Grant et al., 2019; Kim et al, 2018; Madigan & Kim, 2021). We only need to look at the rates of dysregulated behaviors and mood disorders in our youngest children (CDC, 2021; Whitehouse.gov, 2021); expulsion numbers from preschool and early childhood care programs (Gilliam & Shahar, 2006; Steglin, 2018); shortages of quality childcare, the high rates of pediatric mental health problems (Duong,et. al, 2021; Vasilevaet al., 2021); increases in professional burnout and attrition rates (Bassok, et al, 2021; Farewell et al., 2023; Hur et al, 2023; McMullen et al, 2020; Shim et al., 2022); and the rise in adult mental health challenges (Gose, 2023). Although the pandemic may have contributed to these issues, the problems were escalating prior to 2020 (Greenberg et al. 2001; Whitebook, et al, 2014) and continue to have increasing and significant implications for outcomes for child and family populations as well as professionals. Consider that currently a significant number of children may be inappropriately red flagged for and/or diagnosed with Autism Spectrum disorder (ASD) (Fombonne, 2023; Rowland, 2023; Ulbricht, 2024) and ADHD (Kazda et al, 2023; Morgan et al, 2023; Ulbricht, 2024). While it is understood early detection of ASD may result in better long-term outcomes, inappropriate diagnoses can have equally significant but negative ramifications as can misdiagnoses of ADHD.
In part, these issues may stem from focusing solely on behaviors while minimizing what underlies them, consequently overlooking the driving problem (Delahooke, 2020; Siegal, 2020). This perspective then promotes a tendency to focus on the child as the identified ‘patient’ rather than understanding the child in broader contexts, such as family systems, the environment, trauma, and ongoing changes wrought by development (Bronfenbrenner, 1977). For example, an 18-month-old was recently red flagged for ASD and referred for early intervention. The referral was made because the child consistently laid on the floor, screamed at and kicked his mother. However, no one asked about the mother or the dyad. In fact, the young mother was significantly depressed, non-responsive, and had not been able to bond with her child from the beginning. Consequently, the child’s behavior was not inappropriate for the circumstances. He needed an engaged, loving caregiver, but there was none to be had. His behavior was his only means of communicating the problem. ASD was not, in fact, the issue but by focusing on the behavior, the real problem was going unaddressed.
The handling of these kinds of challenges often reflects a reactive mindset which emphasizes management as opposed to understanding. This is further fueled by the limitations of the DSM V, which is constrained, at best, in its characterization of childhood disorders, not adequately accounting for factors such as family dynamics, sensory functioning, physiology and development (Cuthbert, 2015). However, many child professionals, such as educators, early interventionists, health, mental health, and allied health providers have not received the formative training to understand and/or address these complex issues, especially when related to social emotional development, individual differences, sensory/temperament profiles, and the effects of culture, family, and classroom on child functioning.
These limitations often result in mis-cued interactions, misdiagnoses, and/or inappropriate interventions, which then distort perceptions of and relationships with the child and compromise outcomes. Further, the limitations minimize or render invisible relational health, which is foundational for positive development. They also skew assessments and choice of interventions. Further, while the rates of ASD and ADHD (an inappropriate diagnosis for infants and young children) have increased since Covid, there is insufficient understanding of parent and professional stress rates, mental health issues, potential grief, and dysregulation, all of which can affect children’s behaviors (Abdelnor et al, 2022). While efforts are being made to address some of these problems, there continues to be gaps in understanding about the nature of the problems and, hence, how to address them.
The Shift
As noted, across multiple disciplines there is an overemphasis on behavioral models, which do not adequately account for the other contributing factors that can underlie behavior (Cuthbert, 2015; Delahooke, 2020). Even training that aims to incorporate reflective and relationship-based components often does so at levels that the professionals cannot yet make use of as they lack the necessary foundation. First and foremost, training must begin with the development of an understanding of self and then self in relation to others. That is, one has to build an awareness of the effects of one’s own history, triggers, biases, and strengths, in order to then be able to reflect on them and then how these factors affect their work with children and families. This is especially important when working with others different from us as we need to develop an understanding of another’s meaning making, including how their culture shapes their perspective and understanding of the world (Toren, 2008).
Consequently, we need to support reflection beyond assessing whether an activity went well or not. Instead, it needs to be reframed as the capacity ‘to be’ with oneself and others. This means learning to pay attention to feelings via our bodies, then using this information to better understand how we feel about and are reacting to given circumstances. What are we bringing to our interactions and how may this affect the people with whom we work – and vice versa. This is vital as these processes facilitate better assessment skills, regulatory capacities, and, importantly, abilities to build effective working relationships with all children and families. As such, education and training should include an emphasis on the internal (felt) experiential processes, beginning with our own histories, especially in regard to our earliest relationships and how they have shaped us.
Where we Begin
The first step is the relationship between the trainer and trainee, which builds over time. Through interpersonal processes, curiosity and enquiry, professionals can begin to develop an awareness of strengths, areas for growth, and an integrated understanding of physiology, temperament, and relational histories. How do we feel and move through the world? Do I need a high level of social engagement, or do I prefer it in smaller doses? Am I calm in noisy spaces, or do they dysregulate me? Can I easily shift from one mental activity to the next? Or do I need more time to process? How do I feel in my body? How do I feel when others are dysregulated? How have my earliest relationships, experiences, and environments affected how I feel today? How has my background and culture shaped my perspective of and feelings about others and the world?
This should start at the earliest stages of professional education and training. Currently, at undergraduate and graduate/professional levels, curriculums are still constricted, often using outdated syllabi and concepts that don’t address real world problems, especially in the social emotional realm. Moreover, there are assumptions that all students’ funds of acquired knowledge and experiences are similar. That is, we teach and train as if everyone shares the same foundation, has similar backgrounds, learns the same way, and at the same rate. Experience, students, and professionals tell us otherwise. As such, many move into professional spaces without the needed education and training to do the work they will be required to do.
To redress these issues, education and training should include ongoing interpersonal components and reflective work. Over time is especially important as it is a process to build an understanding of self and to integrate knowledge into real world practice. Moreover, it is important to hold in mind that, for many, reflecting on one’s own emotions, triggers, and histories and even strengths – ghosts’ (Fraiberg et al, 1972) and ‘angels’ (Lieberman et al, 2005) – may be new experiences, and, occasionally, dysregulating and overwhelming. As such, this underscores the need for a measured process as individuals move through the learning experiences in their own ways.
Without the reflective foundation, professionals are more apt to jump to conclusions, struggle to meet parents or children where they are at, adequately manage their own stress, and maintain regulation. In turn, this makes it more likely that judgment, stress, and bias will creep in while empathy wanes, increasing the possibility of burnout and attrition. It is important to note that these issues affect more than interpersonal dynamics; quite often these unaddressed difficulties inform how systems and policies are developed and implemented, perpetuating a range of challenges, not least of which are non-responsivity to family needs, systemic racism, and poorer overall outcomes.
Next Steps
Coming to know and work with self and others is not a textbook proposition or a top-down operation. Instead, it is a multi-layered relational process (Mahler, 2017), including bodily experiences, as well as cognitive ones and is focused on lived experiences. As previously noted, often this is best accomplished in reflective group settings over time, allowing participants to integrate feelings and develop skills. It has been our experience that the work does not become meaningful until participants can immerse themselves in the process. They must have consistent, on-going opportunities to relate knowledge to daily experiences and to appreciate the meaning of individual differences – how each person, from biology to physiology to sensory to social emotional to cognitive to cultural influences, to environment, and to developmental levels, is constructed differently (Cuthbert, 2015). It also takes time to build an emotional language and the abilities to develop shared meaning making. While initially these processes may feel cumbersome, they find natural rhythms as interpersonal work evolves.
Groups
To develop safe reflective groups, case presentations and discussions, relatable to participants’ work, must be at the core. For example, recently an early childhood educator shared an experience with a ‘difficult’ parent. The child was struggling with behavioral challenges and the school wanted the child evaluated. When approached, the parent became distressed, reframing the situation as an inadequacy of the teacher. The teacher thought the parent was ‘in denial’, that the child must be ‘spoiled’ at home, and she (the teacher) was left to deal with the fallout. In her reflective group, the teacher was able to wonder about her angry reaction and assumptions and what triggered them. Eventually, she was able to consider the possibility that the parent may have felt worried, overwhelmed, and concerned about judgement. She also realized she didn’t know much about the parent or how the parent perceived any of their interactions. The teacher was able to reflect on her own anxious state and wondered how that might have affected the interchange. By working through this process with peers who shared similar experiences, it afforded the teacher a better understanding of herself and how she might approach parents moving forward. In other words, the opportunity to be in an ongoing reflective consultation group afforded the teacher and other members the opportunity to shift their perspectives and ultimately how they work.
Conclusion
As we contemplate the challenges across child-related disciplines, we must look to consider shifts in education and training, especially in terms of intra and interpersonal components, interdisciplinarity, and especially the understanding of self. Once we can reflect on and have empathy for self, we will be better able to do the same for others. That is, we need to train to support a whole person approach that includes individual differences across body, brain, and mind, and through a cross-cultural lens. Furthermore, development must always be adequately considered because change is going to happen – in infants, children, and adults – as people move across the lifespan. Finally, only with respect for all, practice, consistency, and care in nonjudgmental spaces and in connection with each other can we best learn to develop new ways of being and the skills we need to support the children and families with whom we work as well as ourselves.
References
Abdelnour, E., Jansen, M. O., & Gold, J. A. (2022). ADHD diagnostic trends: increased recognition or overdiagnosis?. Missouri medicine, 119(5), 467.
Baer, T. E., Feraco, A. M., Tuysuzoglu Sagalowsky, S., Williams, D., Litman, H. J., & Vinci, R. J. (2017). Pediatric resident burnout and attitudes toward patients. Pediatrics, 139(3).s
Bassok, D., Markowitz, A. J., Bellows, L., & Sadowski, K. (2021). New Evidence on Teacher Turnover in Early Childhood. Educational Evaluation and Policy Analysis, 43(1), 172-180. https://doi.org/10.3102/0162373720985340
Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist 513–531.
Cuthbert, B. N. (2015). Research Domain Criteria: toward future psychiatric nosologies. Dialogues in clinical neuroscience, 17(1), 89-97.
Centers for Disease Control and Prevention. (2021). Children’s mental health: Data and statistics on children’s mental health. Centers for Disease Control and Prevention. Retrieved from https://www. cdc. gov/childrensmentalhealth/data. html [Google Scholar].
Delahooke, M. (2020). Beyond behaviours: Using brain science and compassion to understand and solve children’s behavioural challenges. Hachette UK.
Duong, M. T., Bruns, E. J., Lee, K., Cox, S., Coifman, J., Mayworm, A., & Lyon, A. R. (2021). Rates of mental health service utilization by children and adolescents in schools and other common service settings: A systematic review and meta-analysis. Administration and Policy in Mental Health and Mental Health Services Research, 48, 420-439.
Farewell, C. V., Mauirro, E., VanWieren, C., Shreedar, P., Brogden, D., & Puma, J. E. (2023). Investigation of key domains associated with worker well-being and burnout and turnover in the early care and education workforce. International Archives of Occupational and Environmental Health, 96(6), 891-901.
Fraiberg, S., Adelson, E., & Shapiro, V. (1975) Ghosts in the Nursery. Journal of the American Academy of Child Psychiatry vol. 14, no.3
Gilliam, W. S., & Shahar, G. (2006). Preschool and child care expulsion and suspension: Rates and predictors in one state. Infants & Young Children, 19(3), 228-245.
Grant, A. A., Jeon, L., & Buettner, C. K. (2019). Relating early childhood teachers’ working conditions and well-being to their turnover intentions. Educational Psychology, 39(3), 294-312.
Greenberg, M. T., Domitrovich, C., & Bumbarger, B. (2001). The prevention of mental disorders in school-aged children: Current state of the field. Prevention & treatment, 4(1), 1a.
Hur, E. H., Ardeleanu, K., Satchell, T. W., & Jeon, L. (2023, April). Why are they leaving? Understanding Associations between early childhood program policies and teacher turnover rates. In Child & youth care forum (Vol. 52, No. 2, pp. 417-440). New York: Springer US.
Kazda, L., McGeechan, K., Bell, K., Thomas, R., & Barratt, A. (2023). Increased diagnosis of attention‐deficit hyperactivity disorder despite stable hyperactive/inattentive behaviours: evidence from two birth cohorts of Australian children. Journal of Child Psychology and Psychiatry, 64(8), 1140-1148.
Kim, J. J., Brookman-Frazee, L., Gellatly, R., Stadnick, N., Barnett, M. L., & Lau, A. S. (2018). Predictors of burnout among community therapists in the sustainment phase of a system-driven implementation of multiple evidence-based practices in children’s mental health. Professional Psychology: Research and Practice, 49(2), 132.
Lieberman, A. F., Padrón, E., Van Horn, P., & Harris, W. W. (2005). Angels in the nursery: The intergenerational transmission of benevolent parental influences. Infant Mental Health Journal: Official Publication of The World Association for Infant Mental Health, 26(6), 504-520.
Madigan, D. J., & Kim, L. E. (2021). Towards an understanding of teacher attrition: A meta-analysis of burnout, job satisfaction, and teachers’ intentions to quit. Teaching and teacher education, 105, 103425.
Mahler, K. (2017). Intereoception: The Eight Sensory System, AAPC Publishing: Lenexa,KS.
Merten, E. C., Cwik, J. C., Margraf, J., & Schneider, S. (2017). Overdiagnosis of mental disorders in children and adolescents (in developed countries). Child and adolescent psychiatry and mental health, 11, 1-11.
McMullen, M. B., Lee, M. S., McCormick, K. I., & Choi, J. (2020). Early childhood professional well-being as a predictor of the risk of turnover in child care: A matter of quality. Journal of Research in Childhood Education, 34(3), 331-345.
Morgan, P. L., Woods, A. D., & Wang, Y. (2023). Sociodemographic disparities in Attention-Deficit/Hyperactivity Disorder overdiagnosis and overtreatment during elementary school. Journal of Learning Disabilities, 56(5), 359-370.
Rowland, D. (2023). Epidemic of False Diagnoses of Autism. Journal of Neurology, Psychiatry and Brain Research, 1.
Shim, R., Szilagyi, M., & Perrin, J. M. (2022). Epidemic rates of child and adolescent mental health disorders require an urgent response. Pediatrics, 149(5).
Siegel, D.J. (2020). The developing mind: How relationships and brain interact to shape who we are., New York: Guilford Press
Stegelin, D. A. (2018). Preschool suspension and expulsion: Defining the issues. Institute for Child Success, 1-19.
Toren, C. (2008) An anthropology of human development: What difference does it make. In Fogel, A., King, B, & Shanker, S. (Eds), Human Development in the 21st Century. Cambridge, UK: Cambridge University Press
Ulbricht, J. (2024). Overdiagnosis or Underdiagnosis? Considerations for Diagnosing ADHD and Autism.
Vasileva, M., Graf, R. K., Reinelt, T., Petermann, U., & Petermann, F. (2021). Research review: A meta‐analysis of the international prevalence and comorbidity of mental disorders in children between 1 and 7 years. Journal of Child Psychology and Psychiatry, 62(4), 372-381.
Whitebook, M., Phillips, D., & Howes, C. (2014). Worthy work, STILL unlivable wages: The early childhood workforce 25 years after the National Child Care Staffing Study.
Whitehouse.gov (2021) Briefing-room/Statements/release, Fact Sheet: Improving Access in Care for Youth Mental Health and Substance Use Conditions
Authors
Newman, Nina,
School of Psychology, Fielding Graduate University
United States
Glovinsky, Ira,
School of Psychology, Fielding Graduate University
United States
Nina Newman is in the Infant and Early Childhood Development (IECD) program at Fielding Graduate University
Ira Glovinsky is in the Infant and Early Childhood Development (IECD) program at Fielding Graduate University
We have no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to Nina Newman, Fielding Graduate
University, 2020 De La Vina Avenue, Santa Barbara, CA 93105. Email: nnewman@fielding.edu
