Enhancing the Accessibility of Early Childhood Mental Health Interventions: A Qualitative Implementation Study in a School Setting

Background: The escalating prevalence of early childhood mental health issues, worsened by the COVID-19 pandemic, has intensified a long-existing public health crisis, which highlights the urgent need for effective and accessible interventions. Early emotional and behavioral health problems, compounded by adverse experiences such as poverty, present a long-term effect on children’s development. Yet, access to preventive interventions is alarmingly inadequate, with only 20% of affected children receiving the necessary services. School-based delivery models present a promising avenue to reach young children with essential mental health services. Aiming to improve the fit and accessibility of school-based interventions, this qualitative implementation study explores the following: What are the needs of the schools related to early childhood emotional and behavioral problems? What are their priorities? What are the potential barriers and facilitators to implementing the intervention in schools?

Methods: Researchers from Washington University School of Medicine and senior leadership in a local school district met for approximately one year to discuss the feasibility of testing a brief early preventive intervention accessed within the school system. The intervention under consideration was a shortened eight-session variation of Parent-Child Interaction Therapy – Emotion Development (PCIT-ED), which focuses on child emotion awareness and regulation. As a part of the pre-implementation of PCIT-ED, face-to-face semi-structured interviews with 27 pre-k – 2^nd grade teachers and a focus group with 9 psychologists/social workers/counselors were conducted. Data collected from the interviews and focus group were analyzed using an inductive-deductive hybrid thematic approach in NVivo 20 to explore the perceived need for a parent-child intervention and appropriateness to educational settings.

Results: Teachers and counselors reported that young children are experiencing what seems to be unprecedented levels of trauma in the home and community, which come into the classroom via emotional and behavioral disturbances. While internalizing problems were noted by most teachers interviewed, they indicated that these do not get as much attention as externalizing problems which are more difficult to manage. Underlying all emotional and behavioral disturbances were high levels of emotion dysregulation. Most teachers feel overwhelmed by and unprepared to respond to challenging child behaviors in their classroom. Some teachers and counselors identified the child’s home life as a contributing factor for problematic classroom behaviors, including unstructured environments with little supervision, chaotic home life, and parental substance use and/or mental illness. However, other teachers and counselors acknowledged the stressors associated with poverty and not having access to basic necessities as the more important contributing factors. Nearly all believed that schools have a role in providing resources to parents to address emotion development. However, discomfort and unwillingness of the parents were identified as potential barriers to the implementation of PCIT-ED in schools.

Conclusions and Implications: This study demonstrated the appropriateness of preschool and elementary school settings as a platform for delivery of PCIT-ED and the receptivity of school personnel to the premise of the intervention. Findings informed the co-development of a feasible plan for screening and service delivery within the schools, and for engagement of parents who may be hesitant to participate.