Little kids, big problems

Why early-childhood mental health services make sense.

By Linda K. Wertheimer
April 25, 2010

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“Just take a deep breath” was the advice one mother got from the pediatrician when she went in for help with her 3-year-old’s extreme tantrums. At a birthday party not long before, he stamped his feet, cried, and shouted when his mother stopped him from scooping a toy car off the cake. They left the party with him in tears, but after the unsatisfactory visit to the doctor, it was the mother who cried.

On a regular basis, the boy threw toys and slammed doors when things did not go his way, says his mother, who asked to remain anonymous to protect her son’s privacy. He never seemed to outgrow the “terrible twos.” Instead, his behavior worsened, and no one – not his doctor, his preschool teachers, or his parents – seemed to be able to help. “I was worried if I didn’t get a handle on it that he was going to end up in juvenile hall,” says his mother.

A few months after the checkup, she spotted a flier for social worker Patricia Marquis’s free workshop, “Raising Your Challenging Child,” held at First Connections, a nonprofit in Concord focused on parent and early-childhood education. It was there that the parents finally received the advice they needed to help their son through a difficult year.

“Many of the people think their child is doing it on purpose,” says Marquis. “I have to help a lot with that.” For this mother, the weekly meetings with Marquis and other parents did help.

“When you’re 3, your life is hard,” the mother says. “You get angry.” Now the boy is 7 and in the first grade, and the daily battles are over. His mother says she believes her son’s behavior improved in part because he matured, but also because she and the boy’s father learned to respond better when he became upset. “He’s still a sensitive kid, and he still gets mad,” she says. “Now he’ll go, ‘Grrr,’ but he doesn’t slam a door.” Expectations are that he will flourish. And as for the mother, “I understand him better,” she says.

Extreme behavior in very young children – not your garden-variety tantrums, but aggression, paralyzing anxiety, and other severe problems – is increasingly being addressed by researchers, educators, and lawmakers. A 2005 Yale study helped spur the change: Professor Walter S. Gilliam found that 3-and 4-year-olds were being kicked out of publicly funded preschool programs at an alarming rate. In Massachusetts preschools, which the study ranked ninth highest in the nation for expulsions, eight children per 1,000 were kicked out, more than 34 times the rate for kindergarteners in the state and more than 13 times the national average for preschoolers. Experts agree, though, that expelling very young children is not the answer. “To expel children from a school readiness program is to expel a child from the program [he or she] needs the most,” says Gilliam. “It’s almost like kicking people out of a hospital because they’re too sick.” So now nonprofits and the state are funding mental health services and other related programs, based on the idea that working with the very young is often more effective than waiting until troubled children become troubled teens or adults.

A 3- or 4-year-old’s job is to get ready – socially mostly – for kindergarten, and for many families, that happens at preschool and without any trouble. But some kids need help. A decade ago, children exhibiting extreme behavior in preschool often floundered. They bounced from one program to the next and often fell behind their peers. More of them than necessary, say mental health and education experts, ended up in special education classes once they entered school.

Cheryl Pasquariello’s grandson was only 3, but he had already been kicked out of one day-care center. His aggressive behavior was bordering on violent when, after he was removed from his parents’ care, he moved to Worcester to live with his grandmother. He slammed doors. He threw tantrums. He screamed.

Pasquariello was desperate for help when she enrolled him at the local YWCA’s preschool. She needed to work. And more than that, she needed help with the boy, who, having lived in several homes, didn’t trust any adults, Pasquariello says, and did not even know how to hold a pencil.

At the preschool, the boy at first refused to talk to any grown-ups. He was alternately aggressive and withdrawn. When it was time to change rooms for an activity, he dropped to the ground and covered his head. He refused to leave until the rest of the class exited.

The Worcester YWCA was a lucky find for the family. Kelly Gratton, a mental health consultant there, began observing Pasquariello’s grandson from his first day. Once or twice a week, Gratton met with the boy for an hour, and early on she met weekly with the grandmother, too.

In her office at the Y, Gratton would let the boy choose a toy and then listen and talk with him as he played. A dollhouse was his favorite, and he filled it with furnishings and people. Gradually, his behavior improved. Now in kindergarten, the boy sees Gratton at Community Healthlink, the nonprofit mental health agency where she also works. The boy’s natural charisma and loving personality have begun to shine through, she says, but she also predicts that he will need counseling for years to come.

His grandmother is hopeful. In kindergarten, for the first time, the boy and a friend had a play date at her home. They played with trains and watched a movie. The program has helped her take better care of her grandson, Pasquariello says. A year ago, Pasquariello says, she would have left her grandson to sulk in his room after an outburst. Now, she still sends him to his room, but then they talk about what happened. At home, they speak the same language about behavior because of lessons both have learned from his counselor.

Medical issues, too, can cause disruptive behavior, and many go undiagnosed in such young children. “The challenge with toddlerhood is there is a big range of what’s normal,” says Joshua Sparrow, a Harvard Medical School child psychiatrist. “That is part of the explanation about why some kids don’t get help.” But once a problem is identified, resources are available, even to preschool-age children, through the public schools – families just have to know how to get them.

One girl, now in public kindergarten in a western suburb, began to have difficulties around age 3 both at home and at her private preschool. When it was time for the children in the girl’s class to play outside, she refused to put on her coat and boots. Once outside, she often cried and stood alone picking up stones. She was extremely fussy, and she was frustrated by her inability to do routine tasks. Her parents initially chalked up the behavior as the typical defiance of a 3-year-old. The mother worried that she was aggravating the situation by being too strict.

“It was pretty much every hour,” says her mother, who also requested anonymity for her child. “She was always crying, and she was always complaining that she was tired. I heard a lot of, ‘I can’t,’ and it was before she would even try.”

This mother, too, found the challenging-child workshop at First Connections in Concord. She applied for a spot and, after discussing the girl’s behavior during the screening process, the agency’s executive director loaned the mother a book on sensory processing disorders. These varied conditions can include a skewed sense of space, making people and things seem closer or farther away than they are, and delayed motor planning – the ability to think through and carry out a task – making dressing or putting on a coat and boots seem like insurmountable tasks.

After joining the workshop and learning more about both sensory processing disorders and the services available through their public school district, the parents had their daughter evaluated by experts at the schools. A team of four specialists tested the girl and concluded that she had sensory impairment and a developmental delay. The school system provided a program of occupational and physical therapy that continues today.

At home, the girl’s parents are also working to help her cope. Each night, mother and daughter pick an outfit for the girl, as well as one for her little brother. In the morning, the mother coaches her daughter through the steps of dressing, which helps her manage. Today, academically, she is above average. Yet physically, socially, and emotionally, her mother says, “I think she’s still catching up.” The mother says that her daughter may never be an athlete or a social butterfly. But the expectation is that, in the long term, thanks to early help, she will be able to succeed in school.

The First Connections Workshop and Worcester YWCA counseling programs, both of which have been established for about a decade, were pioneers in early-childhood mental health services. The 2005 Yale study raised awareness and, more important, funding for these types of services. That next year, in direct response to the study, the United Way of Massachusetts Bay and Merrimack Valley started the nonprofit Connected Beginnings, says Betsy Leutz, the organization’s acting executive director. The Boston-based program trains infant and early-childhood mental health counselors; state and federal grants to community health agencies as well as some health insurance policies pay for children to get counseling services.

But mental health services for young children don’t seem to be a high priority now, in a time of economic downturn. State funding, which started out in 2001 with a few pilot programs, was $1.4 million for the 2008 fiscal year, then rose to $2.4 million in 2009, but dropped to $1 million for 2010, according to the Department of Early Education and Care. The governor’s request for the 2011 fiscal year is $1.5 million. Roughly 80 cities and towns draw from the funds.

The Worcester YWCA program, in its ninth year, illustrates on a small scale the effects that spending on mental health services for preschoolers can have. Gratton, who used to spend 20 hours a week with the children at the Y, now is only there six to eight hours a week, says executive director Linda Cavaioli.

In 2001, the year before the Worcester Y started mental health counseling, seven children there were expelled from the two programs serving 114 children, and teacher turnover was close to 40 percent. In the years since, as mental health counseling was made available to kids who needed it, teacher turnover has dropped to 9 percent, she says, and the expulsion rate has fallen to zero. Cavaioli attributes the improvement in both areas directly to counseling, and she says that a third of the children – the same ratio as before – come in with behavioral problems.

There is also academic research suggesting mental health counseling can save money in the long run. “Teachers will say, ‘Once the behavior settles down, development takes off,’ ” says Carole Upshur, a researcher at the University of Massachusetts Medical School Worcester. Normally, she says, if they do not get help in preschool, children with behavioral issues are put into special education in kindergarten whether or not they have a diagnosed problem. Special education classes, of course, cost the state more than standard kindergarten. According to Upshur’s preliminary findings, which are based on small sample groups, giving preschool-age children early help with behavioral problems means that fewer kids need special education when they start kindergarten. The equation is simple, Upshur says. Spend more on efforts to help children earlier, and the state saves money in the long run.

Linda K. Wertheimer is the former education editor for the Globe. Send comments to

(Illustration by Sol Linero)
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