Phil Wilson: GP and senior lecturer in infant mental health at the University of Glasgow
Phil Wilson argues that pre-school influences shape
children's social, physical and emotional development and that
evidence shows that wise investment to improve outcomes for
pre-school children can pay a rich social dividend.*
Children's experiences in early years lay down the foundation
for the rest of their lives. Pre-school influences shape children's
social, physical and emotional development long after they start
Costing pre-school benefits
Spending on pre-school years gives the highest rate of return on
investment in human capital (Heckman and Masterov 2005). But,
despite this, most is spent on universities and least on pre-school
service provision (Alakeson 2005). Our pattern of educational
expenditure thus seems to be designed to produce the minimum
return. General public expenditure on the under-threes is minimal
when compared with expenditure on any other age group, with
specific expenditure being largely restricted to health visiting
and some preferential benefits payable to unemployed mothers. This
pattern of low expenditure on this period of life is perhaps most
exaggerated in mental health provision. In most parts of the UK,
mental health professionals rarely see children under three, and
services tend to be provided by general practitioners, health
visitors and paediatricians. Although some health visitors are now
being trained in infant mental health, few doctors caring for young
children have had such training.
Getting a good start
Many long-term studies, particularly birth cohorts, (Thompson et
al. 2010; Jaffee et al. 2002; Jones et al. 2002; Murray et al.
2010) have identified preschool factors associated with poor mental
health and violence later in life. These may be:
- Genetic (e.g. vulnerability to autism, Attention
Deficit/Hyperactivity Disorder (ADHD) or anti-social personality
disorder) (Caspi 2002)
- Antenatal (e.g. maternal stress hormones, smoking and alcohol
- Located in the family/upbringing (e.g. postnatal depression,
harsh or inconsistent parenting, parental discord)
- Located in the wider environment (e.g. relative poverty,
These factors may interact in different ways. Sometimes the
risks may simply add up, sometimes they may amplify each other, and
sometimes they may apparently reduce each other's individual
effects. For example, some of the adverse effects of antenatal
smoking are accounted for by the fact that mothers who smoke when
pregnant are more likely to have postnatal depression (Maughan
There are factors which increase the resilience of children's
brains to adversity. Positive parent-infant interaction protects
against childhood psychological problems (Bradshaw and Tipping
2010). Higher intelligence, particularly in verbal abilities, is
also protective (Emerson, Einfeld and Stancliffe 2010).
UK policy has tended to prioritise child abuse over child
neglect, partly because of its greater visibility and media impact,
and partly because of the relative ease of definition and
simplicity of planning care pathways (Wilson and Mullin 2010).
Neglect is, however, a much greater social problem and probably
causes more long-term psychological difficulties. For example,
Kotch et al. (2008), based on a robust study from the US, concluded
that ...child neglect in the first two years of life may be a more
important precursor of childhood aggression than later neglect or
physical abuse at any age. While the impact of neglect is likely to
become apparent when children enter school, there is a compelling
case for earlier identification. Making this case has proved
difficult (partly because of the difficulty of research in this
area) (Wilson et al. 2009) but there is a considerable indirect
evidence supporting the view that we should be assertive in seeking
cases of neglect in order to support families and reverse its
long-term effects. The fact that only a tiny fraction of children
living with problem drug or alcohol use in the family are subject
to even basic child protection procedures, shows that we are
failing to protect the most vulnerable children.
The value of early interventions
Early support to vulnerable families by nurses is highly
effective, and cost effective. For example, David Olds' landmark
trials of the Nurse-Family Partnership† offered to
vulnerable mothers in the US have demonstrated that about 30 hours
of input between mid-pregnancy and the age of two, at an
approximate cost of £3,500 (Olds et al. 1993), can halve criminal
behaviour, substance use, smoking, running away and high-risk
sexual behaviour by age 15 (Olds et al. 1998). Each of these
behaviours has been shown in various studies to be associated with
future morbidity, both physical and mental. Other work has
confirmed the strong association of such behaviours with mental
health problems. Nurses are much more effective than
paraprofessionals (Olds et al. 2002), and continuity of care has
been found to be crucial. Olds' work is unusual in that study
participants were followed up meticulously for many years, and
there are no other examples of such rigorous assessments of nursing
interventions. There are, however, excellent evaluations of early
nursery-based interventions, most notably the Carolina Abecedarian
project (Campbell et al. 2002), which produced dramatic long-term
benefits in academic achievement and problem substance use. The
Scottish Collaboration for Public Health Research and Policy has
recently published an excellent summary of the impact of early
interventions (Geddes, Haw and Frank 2010).
It has not proved possible to achieve results as good as Olds'
when interventions have been offered to teenagers to reduce
unhealthy behaviours such as smoking, drug use and high-risk sexual
behaviour. Other compelling evidence suggests that violence and
antisocial behaviour is best tackled in the pre-school years
(Wilson et al. 2009). It seems that we 'learn' how to be violent
very early (Tremblay 2008) and it is also easier to undo behaviour
patterns at a young age.
There are many examples of problems where intervening early is
better than intervening late, but language delay is a particularly
clear example. There are 'critical periods' (Bailey et al. 2001) in
language development, and if we miss the window of opportunity, a
child's language will be permanently impaired. Also, early language
delay is a very powerful marker of psychological vulnerability. In
a large Swedish study (Miniscalco et al. 2006), children aged 30
months, who could not make two-word utterances and who had fewer
than 50 words, had a 70% probability of having a psychiatric
diagnosis, most commonly autism spectrum problems or ADHD, at age
Language delay is a potential sign of neglect - most young
looked-after children have such problems, and language problems are
extremely common in children excluded from school (Ripley and Yuill
2005). So language delay is a very important early warning sign,
and does not just go away. We must identify and assess these
children quickly and carefully, and offer intervention (usually
more than speech and language therapy) if we are to avoid major
Patterns of vulnerability
Our research group at the University of Glasgow recently
conducted a pilot project in which families were offered two new
universal contacts with their health visitor when children reached
13 months and 30 months.
The project used structured assessment tools because this is the
best way to ensure social equity; otherwise there is a high risk
that interventions would be offered to those who least need them as
detailed in the 'inverse care law' (Hart 1971). The work was
designed to assess need (including unmet need) for parenting
support in the community and offer appropriate levels of service to
families. We assessed parental wellbeing and the parent-child
relationship (Wilson et al. 2010) at 13 months; language delay
through a two-question screen (Miniscalco et al. 2006), behaviour
problems and parental stress at 30 months; and family background
and demographic factors at both ages.
We identified a great deal of previously unsuspected need. For
example, 8% of parents who had been assigned to the lowest risk
category by health visitors had strong evidence of depression. At
30 months, 10% of children were found to have some degree of
suspected language delay: 47% of these children had been assessed
as being at low risk at the start of the visit.
Further work has been conducted with the Scottish Government and
Glasgow City Council to develop the assessment of children's
emotional and behavioural wellbeing at school entry using the
'strengths and difficulties questionnaire' (Goodman 1997; Goodman
2001; Youth in Mind n.d.). This data has allowed us to describe the
emotional and behavioural wellbeing of children entering school in
Glasgow. We now have maps of the distribution of emotional
problems, hyperactivity/ inattention problems, conduct problems,
and peer relationship problems across Glasgow The prevalence of
conduct and hyperactivity problems is roughly 50% higher in the
most deprived parts of the city compared to the most affluent, but
some of the most deprived areas appear to have excellent childhood
mental health. The data will allow us to identify local and
individual factors predictive of problems likely to interfere with
children's school attainment and will provide a baseline for future
How should we respond in the UK?
It is important to view the great achievements of David Olds'
Nurse-Family Partnership in context. In the US, there is no
universal health visiting service and, consequently, no mechanism
for identifying actual need in individual families in the
community. Offering the Nurse-Family Partnership intervention to
all families is clearly impractical, expensive and unjustified. It
has to be a targeted, rather than universal, provision. Directing
attention to families on the basis of predicted vulnerability
(using, for example, lone parent status, teenage pregnancy, and
economic adversity) without further assessment is inefficient at
best: it gives resources to families who do not need them, and
misses many children with substantial need who do not fall into the
'right' demographic group. Our recent evidence from Glasgow
confirms this view. We have the potential for an efficient and
flexible use of resources through an 'active filtering' approach in
which professionals and families together determine level of need
with reference to standardised assessment tools (Wilson et al.
2008a). Resources can thus be directed to those most in need. In
other words, we need an intelligent system for 'case-finding', an
assessment of the level of child/family need and appropriate
resource allocation, often called progressive universalism.
The professionals routinely in contact with all children under
the age of three years are: midwives (usually until the child is
10-28 days old); general practitioners (GPs); and health visitors.
Each has the advantage of universal access and, consequently,
contact with them is not associated with stigma. These
professionals lack routine training in infant mental health, and
profess a desire to learn more (Scottish Needs Assessment Programme
2003). In recent years, several policy developments have tended to
reduce GP and health visitor involvement with the preventative care
of children to the extent that many children do not see either,
except on an opportunistic basis (for example, during illness)
after the age of four months. One argument for universally offered,
regular, child health surveillance contact with both sets of
professionals is that there is strong evidence that vulnerability
is not a static characteristic, but can become apparent at any time
in a child's early years (Wright et al. 2009). There have been some
welcome recent developments both in England, where a commitment to
increase health visitor numbers has been announced (Department of
Health 2010), and in Scotland, with a new mandate for universal
contact with children, focused on language and behaviour.
Finally, once vulnerability is established, there must be clear
care pathways available to families, with almost immediate
accessibility. There is no excuse for a wait-and-see policy in
early childhood social and emotional development.
There is a large body of evidence that wise investment to
improve outcomes for pre- school children can pay a rich social
dividend. The evidence available (Geddes, Haw and Frank 2010),
supports the intuitive view that we get the biggest payback from
investing more in supporting those children with the biggest needs.
However, as Marmot makes clear, it is also important that these
targeted services should be underpinned by universal services, the
need for which is less intuitive. The scale and intensity of
services needs to be proportionate to the level of need.
Assessing need, however, requires targeted investment in the
universal services for children under three - health visiting and
There needs to be a commitment to training and professional
supervision, to universal health surveillance programmes involving
direct contact with children, and to functioning information
systems. In the interests of social equity, there is a strong case
for universal assessments using validated tools to assess need at
several stages in the pre-school years. This would bring benefits
beyond facilitating an equitable approach to support. It could
allow efficient information sharing between primary care
professionals, currently beset with problems (Wilson and Mullin
2010; Wilson et al. 2008b), and help policymakers and managers
evaluate how well early years' services are performing.
Professional training for health visitors should have a strong
focus on infant and child mental health and early brain development
(Wilson et al. 2008b; Wilson et al. 2008c). Universal adoption of
the Solihull Approach to infant mental health (Blackwell 2004)
would promote effective communication among professionals about the
mental wellbeing of pre-school children.
Child neglect needs to be identified early and addressed
wherever possible, and certainly before the child begins to display
serious problems which are difficult to contain. Behavioural
symptoms in pre-school children should be taken as seriously as
they are in adolescents and adults. Persistent aggression and
indiscriminate friendliness, for example, should provoke
professional concern and detailed investigation.
Once identified, there is a need to provide care pathways for
problems such as child neglect and language delay. We are currently
providing inadequate services to children with these
* A version of this article first appeared
in Thinking Ahead: why we need to improve children's mental health
and wellbeing, a Faculty of Public Health publication 2011. Thank
you to the Faculty of Public Health for permission to reproduce
† In the USA, this programme is
called the Nurse-Family Partnership. In the UK, it is generally
referred to as the Family Nurse Partnership.
About the author
Phil Wilson is a GP and senior lecturer in
infant mental health at the University of Glasgow. He contributed
to the Scottish Needs Assessment Programme on Child and Adolescent
Mental Health and the HeadsUpScotland Infant Mental Health report,
and has published numerous academic papers on early childhood
mental health. He is currently involved in evaluating the parenting
support strategy for Glasgow and in research designed to improve
early identification and treatment of psychological and psychiatric
problems in infancy.
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