Tutorial 9 · Implementing and Evaluating ECMHC Services
Defining the Concern and Diagnosis
Defining the Concern
Early childhood mental health consultation is primarily focused on promotion, prevention, and intervention in the ECE setting. In general, mental health consultants gather information and use screening, and assessment strategies to define the concern rather than determine a formal clinical diagnosis.
When defining the concern in a consultation model, the consultant must find ways to describe the child's behavior, any observations and screening/assessment results, and hypotheses about the challenges of meeting the child's needs in the early care and education setting in ways that are meaningful and culturally relevant to the child's family and care providers. In this “dialogue” with families and providers, the consultant engages all of the adults in the effort of “co-creating meaning” – interpreting behavior and developing hypotheses – and identifying contributors to the child's behavior. Along with developmental stage, individual differences, the child care environment, the home environment, and unmet social and emotional needs, culture must be considered as an important contributor to the child's behavior at home and in the child care setting (Johnston & Brinamen, 2006). Some concerns may be related to conflict between the home culture and the culture of child care. In collaboration, these cultural differences must be addressed in defining the concern, developing an explanatory model for understanding the child's behavior, and moving toward planning any intervention.
Although, in general, mental health consultants do not provide a formal diagnosis in the consultation model, it is important for consultants to have knowledge of and be able to help families and staff understand any clinical diagnosis that is given to those young children with serious behavioral and developmental concerns. The science of early childhood development tells us that, for some children, mental health problems may begin early and endure (National Scientific Council on the Developing Child, 2008).
For those mental health professionals working with young children and families in clinical settings, establishing and using diagnostic criteria for psychological disorders in young children remains a challenge, especially for those children from a non-Western ethnic or cultural group. In addition, there is the risk that an early childhood mental health clinician who is unfamiliar with a child and family's cultural frame of reference may incorrectly judge culturally bound variations in behavior, beliefs, or experience as psychopathological (Isaacs et al., 2005).
The American Psychological Association (APA) attempted to address diagnostic concerns by amending the Diagnostic and Symptoms Manual IV (DSM) to diagnose problems with appropriate consideration of bio-social and cultural contexts and influences. The Cultural Formulation model supplements the bio-psychosocial approach by highlighting the effect of culture on the individual's symptomatology, explanatory models of illness, help-seeking preferences, and outcome expectations (Hays, 2001, Lo & Fung, 2003). However, there are limitations to the application of the DSM with very young children. To address this challenge, ZERO TO THREE (2005), published and revised the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3R). The DC:0-3R identifies and describes disorders for infants and young children not described in other classification systems and indicates the importance of culture in diagnostic considerations.
Christensen, Emde, and Fleming (2004) have recommended ways to address cultural perspectives in assessment and diagnosis for use with infants and toddlers. They suggest using a framework and guidance parallel to the APA's version. These important considerations would include:
In addition to helping to frame and inform clinical diagnosis, these same elements could contribute to the early childhood mental health consultant's efforts to complete a child assessment, define the concern in collaboration with families and staff, assist families and staff in understanding any clinical diagnosis, and design responsive interventions.
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