In their paper “Parent Perception of Mental Health Needs in Young Children,” McGinnis and colleagues aimed to investigate child and parent factors associated with parent perception of mental health needs in their young child, and advocate a shift from the individual child to the family in assessment and intervention. How parents perceive possible mental health problems in their young children is indeed a very relevant topic, as parents of very young children are often the principal informants. Child psychiatry has long mainly focused on psychopathology in middle childhood and adolescence. Nowadays, it is increasingly acknowledged that mental health problems and disorders can occur in infancy and early childhood, with similar prevalence rates in early childhood compared to later childhood (Egger & Angold, 2006). Although there is increasing evidence that early intervention at preschool age improves outcome (Campbell et al., 2014; Gleason, Goldson, & Yogman, 2016), the recognition of mental health problems or disorders in children below 6 years and the use of mental health services in early childhood is still limited and lower than in older children (Wichstrøm, Belsky, Jozefiak, Sourander, & Berg-Nielsen, 2014). In this commentary, we will discuss some of the findings reported in this study and further elaborate on theoretical and practical issues concerning a possible shift in child mental health care.

The participants in the study were children aged 2–6 years old, attending primary care pediatric clinics in Central North Carolina, and their parents. The Preschool Age Psychiatric Assessment (PAPA), a structured diagnostic interview with parents, was used to determine whether children had problems that met criteria for depression, anxiety, and externalizing behavior disorders, following classifications as described in the Diagnostic and Statistical Manual of mental disorders (DSM-IV). As the authors mention in the discussion, “multi-method/informant assessment could have increased objectivity of diagnostic and family information.” Indeed, determining the complex nature of mental health diagnoses in children solely based on a structured parent interview is not sufficient in clinical practice. Furthermore, the specificity and predictive value of frequently occurring problems in early childhood in relation to (fully developed) disorders is not always straightforward. This also applies to serious risk factors and to prodromes or precursors, that is when disorders have not fully developed yet, as is often the case in very young children. In this line, relying on the absence of previous autism spectrum (ASD) diagnoses in the sample, as the authors state, may be a too premature assumption and disputable as we know that ASD is often missed in (young) preschool children.

Still, the interview does provide valuable information about symptoms of mental health problems in young children as perceived by their parents. In their study, McGinnis and colleagues found that 38.8% of children who met criteria for a disorder were perceived by their parents as having a mental health need, similar to previously studied rates in school-aged children. This finding was unexpected, as their hypothesis was that parental perception of mental health in young children is lower than in older children and may explain the relatively low level of mental health use in early childhood. The authors suggest that parents of young children may take a “wait and see” approach, even when they think their child has problems and needs help. In addition to parents’ “wait and see” attitude, we should not overlook the fact that socio-cultural factors and the health care systems themselves may often encourage such a “wait and see” attitude and policy for (very) young children. Indeed, there is still a broad tendency to deny or underestimate mental health problems in very young children. Concerns about children being “labeled” at a young age, including stigma about mental health disorders and treatment, could raise a barrier to seek professional care for mental health problems. Such may withhold parents from seeking specialized mental health care but also withhold other caregivers and health care professionals to refer to mental health services. Especially when there is a need for a formal diagnosis in order to gain access to mental health services, as is the case in many countries.

Transdiagnostic and relationship-based approach

Although it is now well known that very young children can suffer from serious mental health problems that fulfill the (developmentally sensitive) criteria for a disorder, there is a shift toward a more dimensional and transdiagnostic approach to mental health issues which could help parents and society to acknowledge that young children may also have mental health needs that warrant intervention (Wakschlag et al., 2019). Examples are transdiagnostic factors and the relational context wherein the child grows up. Temperament traits as self-regulation and negative emotionality, cross-disorder-symptoms as sleeping problems, and concerns about attachment development may be risk factors as well as precursors and even part of the disorders themselves. Here the “Diagnostic and Classification of mental health and developmental disorders of infancy and early childhood” (DC:0-5) is a useful tool to address the different contributing facets and their connections, including transdiagnostic factors such as physical health, stress factors, temperament, and the context of relationships, all relevant for understanding and intervening in mental health problems. This multi-level information will help to shed more light on the risk and protective factors involved in parental perceptions of mental health problems and needs.

Interesting is the finding that young children fulfilling criteria for depression were more often perceived by parents as in need compared to children with externalizing disorders. This contrasts with past research where externalizing problems in young children were the most predictive of mental healthcare use (Wichstrøm et al., 2014). A current explanation for externalizing disorders and symptoms leading to higher help seeking is that these are more overt than internalizing symptoms and cause more burden for caregivers. The authors discuss their contrasting finding by suggesting that there might recently be more attention for internalizing problems in early childhood. We propose that other explanations should also be considered, such as the link that has been found between depressive symptoms in (early) childhood and attachment insecurity, or more broadly formulated, with significant problems in the parent–child relationship. This would fit with the authors’ finding that particularly parents reporting depressive symptoms, a risk factor for parent–child relational problems, perceive mental health needs in their children. This is an example of connections that may be found between different factors at child level and the level of parent–child relationships. Such connections may inform prevention and intervention programs that focus on relationships, in line with an early childhood perspective on mental health.

Parental and socio-cultural considerations

Also interesting is the finding that mothers with moderate-high depressive symptoms were twice as likely to perceive a mental health need when children fulfilled criteria for a mental health disorder compared to parents with no or mild depressive symptoms. The authors argue that the average number of symptoms within the moderate/high depressive symptoms-group was relatively low, suggesting that parents with “low severity” depression could be reliable early informants about their young children’s mental health needs.

McGinnis et al. based parental perception of mental health need on a positive response to two questions at the end of the diagnostic interview: “Are there any things that you think s/he needs help with” and/or “You have told me about many different things. Do you think any of them are problems for him/her?” This leaves unanswered the question whether parents think about formal (pediatricians, mental health service, teachers) or informal (friends, family, religious leaders) help sources (Thurston et al., 2018). It would therefore be interesting to further investigate the thoughts and considerations of parents regarding the mental health need of their young children, as different help sources will certainly have diverging implications for child and family.

As the authors propose, parents’ beliefs about treatment could be a barrier to enter mental health care. Seeking out help for a young child also implies that professionals look at the child in his or her context, including parents, parenting, and the parent–child relationships. Such requires a safe and respectful working relationship with parents, who may otherwise feel attacked and concerned that seeking out for help from mental health specialists increases the risk of referral to child protection services (Gleason et al., 2016).

Providing information about (early) mental health care and the positives of intervention targeting the early developing child and parents’ crucial role in it, together with providing education for mental health care professionals about establishing a safe and cooperative working relationship with parents, will help to lower the threshold for accessing mental health services. Such a working relationship invites parents to safely communicate their doubts and fears and acknowledge their needs and values. In addition to the parent–child relationship, it is also the relationship between parents and other caregivers, and between mental health professionals and other professionals that matters in early childhood. Realizing that communication among these relationships is important, it would be interesting to investigate not only how parents perceive mental health need, but also how communication could be improved to help bridge the gap to mental health care.

More research is needed using multi-method and multi-informant assessment which could generate increased objectivity of diagnostic information about the children, their caregivers, and relevant relationships. In future work, it would be important to eminently investigate samples that now fulfill the exclusion criteria, like samples where there is no accompanying partner, samples showing lack of English fluency, and samples with child intellectual ability and (early signs of) ASD.

Although more research is needed, we agree that results support a shift in clinical assessment from the individual child to the family. We would extend this by stressing the relevance of increased attention for parenthood and child mental health issues by adult-oriented mental health providers, as depressive adults may well be reliable early informants about their young children’s mental health needs and as mental health problems in children will certainly impact the parents’ mental health. Active investigation and support for adults who express mental health needs for their children can be expected to have preventive effects. Indeed, when parenting is experienced as very challenging, children even without a diagnosis are at risk. Wichstrøm et al. (2014) found parental burden, parents’ and day care teachers’ perception of children’s needs at age 4 as important predictors of mental health service use at age 7. We suggest to extend the family approach to all relevant caregivers for young children. Not only should society invest in providing information and education for parents about the early signaling and importance of early (preventative) intervention in early childhood but this should also be provided for primary care settings and (day-care) teachers. Suggestions have been made for community systems with developmental monitoring and screening programs to address under identification in early childhood (Barger, Rice, & Roach, 2018).

Concluding, we agree with advocacy for a shift from the individual child to the family in assessment and intervention in early childhood mental health and stretch this even further to the broader context. We have proposed future directions in research addressing parental perception of mental health need and the high psychiatric unmet needs in early childhood. In education about early childhood mental health (problems), prevention, and intervention, we highlighted the relevance of communication with a transdiagnostic, relationship-based, and context-focused approach. Early detection of mental health problems may lead to timely mental health care for children in their relational contexts, before child problems, and accompanying parent-, teacher and interactions between them culminate in serious or persistent mental health problems later in life.

Acknowledgments

The authors thank MOC 't Kabouterhuis and Jeugd GGZ Dimence Group for support. This article had no external funding. The authors have declared that they have no competing or potential conflicts of interest.

Ethical information

No ethical approval was required for this article.