5

Opportunity Gaps in the Social-Emotional Development, Wellbeing, and Mental Health Experienced by Young Children

Opportunity gaps in social-emotional development, well-being, and mental health result from numerous factors experienced both by children and their parents or other caregivers. The committee begins its discussion of these gaps by showing that the path to mental health and well-being in adolescence and adulthood starts at birth (Institute of Medicine & National Research Council [IOM & NRC], 2000): the dyadic relationship that is established between the parental caregiver and infant is crucial to the growing child’s development of self-regulation and social-emotional competence (Sroufe, 2005). In turn, parents’ readiness to engage in the tasks of parenting at the birth of an infant is affected by their own mental health (Kamis, 2021), stress (Vismara et al., 2016), material support (Larson et al., 2008), social support (Luecken, Roubinov, & Tanaka, 2013), and ability to draw on community institutional resources (Rostad et al., 2018).

To set the stage for the discussion in this chapter, some definitions are in order. First, in addressing parents’ mental health and well-being, we are talking not just about formal psychiatric disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013), such as substance abuse disorder, depressive illness, anxiety disorder, and posttraumatic stress disorder, but also about factors that hinder well-being, such as domestic violence, daily work stress, hassles, worry about minimal material goods, lack of neighborhood safety, racism, and pessimism. A child’s healthy development requires more than a parent’s lack of mental illness: the parent must be ready to parent, which requires sufficient emotional well-being and energy to be able to devote attention to the child’s well-being. Second, when we discuss the mental health of infants

and young children, we are referring to the emergent ability to regulate one’s own emotions and behavior; a positive sense of self and agency; appropriate social connections to parents and peers; and freedom from significant internalizing and externalizing behavior problems, attention deficits, and developmental delays.

We assert in this chapter that outcome gaps in overall adjustment in childhood, adolescence, and adulthood result from gaps in opportunities that facilitate positive parent and child mental health and well-being during the early years of life. As discussed in prior chapters, opportunity gaps, in turn, have evolved across generations through biased institutional practices. The good news is that by identifying culpable policies and practices, societal leaders can implement changes that the committee believes hold promise for reducing these opportunity gaps and hence, helping to enable healthy developmental outcomes for all children. This chapter also examines how a parent’s ability to draw on community resources to support the tasks of parenting is a function of historical institutions, laws, norms, and practices, many of which have been discriminatory (Condon et al., 2022). Finally, the chapter identifies policies and practices that affect family functioning and mental health and well-being in the first several years of life as potential targets for efforts to eliminate opportunity gaps in social-emotional development, well-being, and mental health.

CONTEMPORARY CHILD DEVELOPMENT SCIENCE

For many years, educators, pediatricians, and scientists thought that what happened to a child during the child’s early years did not matter much for later development. When universal public education was first contemplated in the United States some 200 years ago, the age at which education would first be offered was established as 7, known then as the “age of reason” (Shapiro & Perry, 1976), or the age at which a child could begin to reason and to absorb instruction. Formal education before that age was assumed to be useless. Only later did early childhood education emerge as a field (Lillard, 2016), through leaders such as Maria Montessori (1966) and Loris Malaguzzi (1998). Likewise, pediatricians used to believe that the focus of early childhood should be on physical health and possibly play. In the 1920s, the American Medical Association publicly opposed governmental support for home visiting to families of infants on the grounds that it would be useless and might even disrupt the mother’s breastfeeding and material support of her infant (Madgett, 2017). Child development science, which offered a new perspective on the early childhood years, became a well-formulated field only in the past hundred years with the theories of Jean Piaget (1936), Lev Vygotsky (1962), and John Dewey (1922).

In contrast, and perhaps to compensate for past failures, contemporary child development science has embraced the importance of the first 5 years of life (and even the prenatal period) as a sensitive period for learning that has a tremendous impact on ultimate life outcomes. The report From Neurons to Neighborhoods: The Science of Early Childhood Development (IOM & NRC, 2000) highlighted the importance of early ecological experiences for brain development, with profound impact across the lifespan. Rapid developments in brain science through imaging (magnetic resonance imaging [MRI] and functional MRI) studies have shown that early traumatic experiences (De Bellis & Zisk, 2014) and poverty (Brito & Noble, 2014) are associated with smaller brain volume and impaired development in critical regions that affect higher cognitive and social-emotional functioning (Bauer et al., 2009). Careful prospective studies of community samples have demonstrated the power of early life experiences, both positive and adverse, to predict later child outcomes (Béatrice et al., 2012).

Scientific findings on child development over the past several decades have shown what kinds of environmental experiences are essential for optimal cognitive, social-emotional, and behavioral development. It is now known that a primary caregiver needs to interact synchronously and reciprocally with an infant for the infant to develop a secure dyadic attachment (Ainsworth, 1979) that will enable the infant to use the caregiver as a secure base for venturing into other social relationships with competence and confidence.

Known now as well is that both material and emotional supports are essential for an infant to grow, and the lack of these supports leads to failure-to-thrive syndrome (Scholler & Nittur, 2012). Research has shown that young children reared in orphanages and home environments lacking in sufficient emotional and cognitive stimulation are likely to grow into troubled older children and adolescents (Nelson, Fox, & Zeanah, 2014), and that a sense of physical and emotional safety based on a safe and cohesive home and neighborhood is essential for a young child’s growing sense of efficacy (Bandura et al., 2001).

Infants and young children are now known to need an optimal level of cognitive and social-emotional stimulation (neither overly excitatory nor void of novelty) to develop the cognitive and social-emotional skills that provide the basis for eventual school readiness and long-term academic functioning and adult well-being (Kessler et al., 2005; Mashburn et al., 2008). In current economic conditions that require almost every able-bodied adult living in a home with young children to work outside the home to make financial ends meet, it is extremely difficult for parents of any background to provide all the emotional support needed by young children. Parents therefore rely increasingly on early care and education (ECE) outside the home to supplement the emotional support and cognitive

stimulation they are able to provide within the home. Parents who understand the importance of these community supplements and can access high-quality ECE are able to provide these opportunities to their young children.

It is now known further that opportunities for play and peer interaction without bullying or threat are essential for the young child’s development of social skills that lay the foundation for healthy friendships and emotional well-being (Dodge et al., 2015; Rubin, Bukowski, & Bowker, 2015). And finally, it is known that education can disrupt the intergenerational transmission of disadvantage (Andersen et al., 2021).

HOW DISPARITIES IN CHILD OUTCOMES DEVELOP

The same studies that identify the environmental opportunities that enable young children to learn and grow also provide the basis for understanding that if there are disparities in these opportunities across groups based on income, race, ethnicity, or geography, disparities in outcomes for children will result (McLoyd, Hill, & Dodge, 2005). A growing body of literature, described later in this chapter, shows that some groups of families in the United States are not afforded sufficient opportunities to enable the growth and learning essential for their young children to reach their full potential.

Particularly large inequities exist in the structural supports available to families, leading to disparities in parental stress (Nomaguchi & House, 2013), parenting (Brody et al., 2008), maternal and infant health and wellbeing (Bailey, Feldman, & Bassett, 2021), parent mental health (McNeil et al., 2014), and parental efficacy (Anderson et al., 2015). Disparities experienced by parents in housing, education, job opportunities, health care, and access to community resources are responsible for disparities in their readiness to parent and in the resources available to them to invest in their children in ways essential to a child’s development of essential competencies.

As an example, consider the hypothetical parent who observes that her 36-month-old child is exhibiting frequent temper tantrums and unable to calm down despite his mother’s best attempts. How does this parent know whether this behavior represents a developmental lag and a problem that could be solved with early professional intervention, or merely a modest developmental challenge that will disappear on its own? How does this parent know where to get professional screening and, if indicated, comprehensive assessment that could lead to early intervention that could put this child on a positive trajectory? How does this parent get access to funds that could subsidize professional assessment and intervention? How does this parent come to understand that seeking help is a sign of parental competence and strength rather than parental incompetence and weakness?

Numerous studies show that group disparities exist in all of the domains referenced above. Families from low-income and minoritized backgrounds, in particular, lack access to scientific information and evidence-based interventions that could help parents provide optimal resources to their young children. The inequities are so pronounced that they have fed into some parents’ lack of confidence in science itself and in mainstream professional intervention. The result is that inequities in opportunities continue.

Historical and Current Inequities in Families’ Access to Community Resources

Although the United States is one of the wealthiest countries in the world, it has historically had higher rates of child poverty compared with most other developed nations (Haider, 2021). According to the most recent census data (2019), one in seven (14.4%) children in the United States live in poverty; the rate is even higher (15.4%) for younger children, under the age of 6. Children of color are overrepresented in these numbers, representing 71% of this group of children (Children’s Defense Fund, 2021).

Children from impoverished communities experience a range of inequities with respect to their child care and school settings, health care, and neighborhoods, and these inequities limit their opportunities for optimal developmental outcomes. These disparities in families’ access to community resources (and in their willingness to access those resources) are rooted in four centuries of slavery and racial injustice (Diptee, 2006). A counterargument to the statement that some families are unable to access the community resources they need is that laws and policy reforms over the last half-century have largely reduced the overt racism of the past. While this counterargument can readily be refuted, it must be recognized that parents become able to access community resources and opportunities through relationships and informal networks of peers, and inequities in these culturally based assets will continue to persist even if systemic racism is eliminated. Passive government policy that requires families to lift themselves up by their own bootstraps constitutes passive racism because it enables inequity in access to continue.

Disparities and Opportunity Gaps in Mental Health in Early Childhood

The mental health of young children is critical for their academic outcomes and general health and well-being (Mashburn et al., 2008). Children who experience compromised mental health are at increased risk for later challenges with respect to their physical health, social relationships, psychological well-being, and financial stability (Kessler et al., 2005; Merikangas

et al., 2010). Thus, it is critical to promote mental health in early childhood to enhance long-term mental health and other aspects of well-being for children from impoverished and minoritized backgrounds.

According to nationally representative parent report data (Cree et al., 2018), 17.4% of American young children (i.e., aged 2–8 years) have a mental, behavioral, or developmental disorder, and a substantial evidence base documents mental health disparities based on socioeconomic status and race/ethnicity. Research suggests that these disparities often appear in early childhood and increase throughout childhood, adolescence, and adulthood (e.g., Alegría et al., 2015; Robinson et al., 2017). However, it is difficult to disentangle whether disparities in child mental health are due to socioeconomic status or racial/ethnic minority status given the confounding of these two factors in the United States. Further complicating the issue is evidence that children from minoritized and impoverished backgrounds are more likely to be pathologized with regard to their mental health functioning (Hansen, Bourgois, & Drucker, 2014; Downer et al., 2016; Meek & Gilliam, 2020). Examining national data from the parents of children 2–8 years of age, Cree et al. (2018) found that children from families with lower incomes were more likely to receive a diagnosis of a mental, behavioral, or developmental disorder compared with families with midlevel incomes.

Nevertheless, extant data point to a stark difference in the mental health outcomes for children from low-income backgrounds compared with their middle-class counterparts. A systematic review of the research by Reiss (2013), for example, found that children and adolescents from low-income backgrounds were two to three times more likely than their middle-class counterparts to present with mental health problems. Chronic poverty was associated with higher rates of mental health problems, and children who experienced decreases in socioeconomic status had increased levels of mental health problems. Moreover, mental health disparities related to socioeconomic status were more apparent in younger than in older children (Jones Harden & Slopen, 2022).

A robust literature is focused on mental health disparities among children from different racial/ethnic groups (Gonzalez, Alegria, & Prihoda, 2005; Alegría, Vallas, & Pumariega, 2015). For example, African American children are more likely to have externalizing disorders but less likely to have internalizing disorders compared with their White counterparts (Coker et al., 2009). Relative to White children, Asian American children have higher levels of internalizing problems and inadequate interpersonal relationships (Huang et al., 2012). Overall Latin American versus White children have higher rates of mood disorders (Merikangas et al., 2010), although the ratios within this population vary based on country of origin (e.g., low levels among Central American children). Finally, although the data are scant, Native American children and adolescents may have higher

rates of substance use, internalizing problems, and externalizing problems relative to all other racial/ethnic groups (Sarche et al., 2011). In general, although much of the data on racial/ethnic disparities comes from studies of older children, Alegría and colleagues (2015) point to early childhood as critical for the emergence of racial/ethnic disparities because of the vulnerability to adversity that characterizes this developmental period.

Notably, when socioeconomic status is controlled for in many studies of racial/ethnic disparities in health, the differences among groups disappear (Hayward et al., 2000; LaVeist et al., 2007; Tackett et al., 2017). These findings suggest that the poverty experienced by many minoritized groups may explain their higher rates of mental health problems. As Yoshikawa and colleagues (2012) suggest, however, race and ethnicity may moderate the effects of poverty on mental health, rendering poverty’s impact more pronounced for certain racial/ethnic groups given the risks emanating from discrimination and other factors beyond poverty. Indeed, some studies suggest that race/ethnicity contributes to disparities beyond what can be attributed to minoritized families’ socioeconomic status (Alegría et al., 2015; Assari, 2020). Notably, such disparities may be traceable to the overdiagnosing of young children from minoritized backgrounds as having attentional and behavioral disorders, as discussed previously (Williams & Williams-Morris, 2000; Coker et al., 2016; Ballentine, 2019).

The paths toward optimal social-emotional functioning and mental health for young children reflect the factors that promote young children’s optimal development writ large. As the preceding section of this chapter suggests, young children’s mental health is grounded in individual, familial, and neighborhood processes, including sensitive and responsive caregiving, safe and stable home and neighborhood environments, and opportunities for supports outside the home. However, young children from families with low socioeconomic status and certain racial/ethnic backgrounds are deprived of many of these individual and environmental resources, a disparity that creates a large opportunity gap between them and children from less marginalized groups.

To elucidate the mechanisms that lead to optimal mental health outcomes among children from impoverished backgrounds, Yoshikawa, Aber, and Beardslee, (2012) propose a conceptual framework that identifies three types of mediators between poverty and children’s mental, emotional, and behavioral health: (1) individual factors, (2) relational factors, and (3) institutional factors. Similarly, Alegría et al. (2015) offer a conceptual model for racial/ethnic disparities in child mental health that identifies protective and risk factors, including childhood socioeconomic status, childhood adversity and supports, family structure, and neighborhood factors. Although these two models address two different types of disparities, the mechanisms they identify to explain these disparities are similar on many levels.

On the individual level, specific aspects of child and parent functioning are related to child mental health; they include child stress and behavior, as well as family structure, parent stress, and parent mental health (Yoshikawa, Aber, & Beardslee, 2012; Alegría et al., 2015). For example, Robinson et al. (2017) argue that early childhood stressors can affect children’s neurologic systems, which in turn can adversely affect subsequent social-emotional functioning. On the relational level, children’s experiences of safety, security, stability, and sensitivity from their parents and other caregivers are critical to their optimal mental health. However, the parents of children from impoverished families tend to experience higher levels of stress, which may be associated with more negative parenting practices and ultimately with children’s mental health challenges, such as behavior problems (Mazza et al., 2016; Schenck-Fontaine & Panicio, 2019). Further, research has consistently revealed a strong link between poverty and both parental mental illness (e.g., depression), and child emotional and behavioral challenges (Aber, Jones, & Cohen, 2000; Yoshikawa, Aber, & Beardslee, 2012; Ridley et al., 2020). It is important to note here that some factors on the relational level—including family religiosity, social support, and neighborhood stability—may protect children from low socioeconomic status and minoritized groups against negative mental health outcomes (Alegría et al., 2015).

The higher likelihood of stress in the families of children from low-income and minoritized backgrounds may constitute an opportunity gap with regard to the parenting and other caregiving experiences of these children. The lack of mental health, parenting, and other services for these families may result in lower levels of parental functioning due to a lack of support in dealing with stressful experiences, which in turn may increase this opportunity gap for their children (Lyons-Ruth, Wolfe, & Lyubchik, 2000; Yoshikawa, Aber, & Beardslee, 2012). Children may also experience myriad systemic opportunity gaps, such as institutional factors—including experiences in ECE and school, parental job quality and stability, neighborhood resources, and access to health care—that affect children from impoverished and minoritized backgrounds (Yoshikawa, Aber, & Beardslee, 2012; Alegría et al., 2015).

The quality of school experiences, whether in ECE or the primary grades—including structural quality (group or class size) and process quality (e.g., teacher–child interactions)—can significantly affect children’s mental health (Weist, 2005; Baker-Henningham, 2014; Jones Harden & Slopen, 2022). Many studies on classroom climate have reported that the absence of responsive, supportive interactions with adult caregivers strongly affects young children’s social-emotional functioning (Pianta & Hamre, 2009; Gilliam et al., 2016; Jones Harden & Slopen, 2022). Also linked to negative social-emotional outcomes for young children is the decreased use of effective instructional practices, such as developmentally appropriate didactic and play experiences (Pianta & Hamre, 2009; Jones Harden &

Slopen, 2022). Scholars have suggested that children from low-income and minoritized backgrounds are more likely to experience low-quality ECE and primary school settings compared with their counterparts from middle-income and racial/ethnic majority backgrounds (Iruka, 2022; see Chapters 2 and 3, respectively).

Other research on ECE and school quality has suggested that teacher functioning plays a role in creating mental health disparities. For example, robust evidence shows that ECE teachers perceive African American and Latin American children (especially African American boys) as behaviorally problematic (Gilliam, 2005; Barbarin & Crawford, 2006; Gilliam et al., 2016) when their behaviors are similar to those of other children in the classroom, perceptions that have led to disproportionate rates of suspension and expulsion of African American boys from both preschool programs and the early grades (see Chapters 2 and 3, respectively, for further discussion of this issue).

Extensions of this area of research have documented that the mental health and well-being (e.g., depression, stress) of teachers and child care providers affect their perceptions of children as behaviorally problematic (Gilliam, 2005; Perry et al., 2008, 2010). Many educational programs are supported by school psychologists and other mental health personnel who help teachers develop the capacity to provide social-emotional support in the classroom as well as address the individual mental health needs of vulnerable children (Splett et al., 2013). Head Start programs, which serve low-income children and families, typically have some level of mental health support, such as a consultant who helps teachers create a positive social-emotional climate in their classrooms or addresses the individual needs of children with behavior problems (Yoshikawa & Zigler, 2000; Gonzales-Ball & Bratton, 2019). However, child care centers and homes, as well as schools in poor neighborhoods, often lack the resources to offer such supports (Johnston & Brinamen, 2006; Masia-Warner, Nangle, & Hansen, 2006; Azzi-Lessing, 2010), creating an opportunity gap with respect to the mental health of young children in the early education arena.

Parental job quality and stability are compromised for parents from low-income backgrounds and minoritized racial/ethnic groups. For example, these parents are more likely to have low-paying jobs that offer fewer benefits and are often characterized by greater physical demands, less autonomy, irregular hours, and fewer opportunities for advancement (Morris & Levine-Coley, 2004; Earle et al., 2014). These parents are also more likely to experience job instability and higher levels of job loss. Multiple studies have found these job-related factors to be related to children’s mental health outcomes—in particular, challenging behaviors. For example, Strazdins et al. (2010) found that children of parents who had poorer-quality jobs (e.g., limited security, control, flexibility, and paid family leave)

were more likely to have emotional and behavioral difficulties, especially if they were from low-income families. In her summary of the literature on parental employment and young child outcomes, Heinrich (2014) suggests that low-income mothers’ employment in jobs with nonstandard hours can affect their social-emotional connections with their young children, partly because of the decreased time available to interact with them.

Neighborhood quality has also been linked to children’s mental health outcomes. Some research has focused on neighborhood, whether by socioeconomic status or race/ethnicity, and its relationship to child mental health outcomes (Leventhal & Brooks-Gunn, 2003). For example, neighborhood support appears to have an impact on parents, and the lack of this support may hinder their parenting capacity and thus their children’s social-emotional functioning (Xue et al., 2005). On the other hand, one study found that parents’ lack of ties to their community (i.e., knowing few neighbors) was associated with lower levels of preschool children’s internalizing problems if they lived in low-income neighborhoods (Jones Harden & Slopen, 2022). Other studies have examined the role of the neighborhood built environment in children’s mental health. In a review of these studies, Alderton and colleagues (2019) found mental health challenges in childhood to be linked to less access to and/or fewer neighborhood green or public open spaces. Finally, research has looked at environmental toxins, finding that early childhood exposure to air pollution and lead paint, among other toxins in their neighborhoods, may lead to higher levels of mental health problems, such as attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD; Morello-Frosch & Shenassa, 2006; Payne-Sturges et al., 2019).

A key opportunity gap lies in access to and engagement in mental health care among low-income and minoritized groups (Bringewatt & Gershorff, 2010). The Institute of Medicine (now the National Academy of Medicine; Institute of Medicine, 2003; McGuire et al., 2006) has defined a health service disparity as differences in treatment and/or access that are not explained by differences in groups’ health status or preferences. Using such a definition, many studies have documented disparities in mental health services for low-income and racial/ethnic minority groups in the United States (McGuire et al., 2006; Morello-Frosch & Shenassa, 2006; Alegría et al., 2015; Marrast, Himmelstein, & Woolhandler, 2016). For example, Cree and colleagues (2018) report that young children from low-income families were less likely to see a health care provider and to receive needed care for a mental or behavioral disorder compared with their counterparts from higher-income families. In a review of the relationship between poverty and mental health services, Santiago, Kaltman, and Miranda (2013) suggest that the majority of children from low-income backgrounds who need mental health services do not receive them because of logistical challenges, parents’

perceptions about mental health services, and system-level barriers. However, some research points to a strong sense of racial and ethnic identity as a protective factor for minority mental health, as it can combat system-level barriers (i.e., racism, discrimination) and strengthen social network support (Sellers et al., 2006; Edwards & Romero, 2008; Birman & Simon, 2013; Morris et al., 2021).

Although disparities in access to and engagement in mental health intervention and treatment by socioeconomic status are a critical consideration, access to and engagement in mental health promotion and preventive services are equally important (IOM & NRC, 2009). For example, universal programs such as home visiting and social-emotional learning approaches in school and child care settings have been found to improve children’s social-emotional outcomes (Zhai, Raver, & Jones 2015; Sama-Miller & Baumgartner, 2017). Although there is a federal home visiting program—the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program—that is targeted to low-income families, it does not serve close to the number of potentially eligible families. According to the National Home Visiting Resource Center 2021 Yearbook, there are potentially 16.4 million families with young children who are eligible for home visiting services through MIECHV; in 2020, 71,000 families were served. Similarly, child care centers serving low-income children (apart from Head Start) lack the resources to incorporate specialized social-emotional services (Azzi-Lessing, 2010).

Individuals from minoritized groups are also less likely to have their mental health needs met, as evidenced by the rates and patterns of use of mental health services among these groups (Chow, Jaffee, & Snowden, 2003; Guevara et al., 2005; Marrast, Himmelstein, & Wooldhandler, 2016). Specifically, individuals from minoritized groups are underrepresented in outpatient mental health services but overrepresented in inpatient and emergency treatment (Chow, Jaffee, & Snowden, 2003; Marrast, Himmelstein, & Wooldhandler, 2016), a differential that may be attributable to the lack of treatment during the early phases of mental health challenges. Additionally, research suggests that individuals from minoritized groups are more likely to have their treatment prematurely terminated, are less likely to have appropriate insurance coverage, and are more likely to consider mental health problems in the context of religious and cultural beliefs around healing instead of engaging with professional providers (Chow, Jaffee, & Snowden, 2003; Loewenthal, 2006).

According to Alegría and colleagues (2015), children and youth from minority groups have lower utilization of mental health services compared with their White counterparts despite their greater need for those services. Likewise, Butler and Rogers (2019) underscore that African American and Latino children and youth are less likely to receive specialized mental health care for such issues as substance use and depression. These authors

also emphasize that minority children and youth are less likely to receive mental health services in other child-serving sectors, such as schools and the child welfare system.

In addition to disparities in access to mental health treatment, researchers have examined issues relevant to mental health service providers. Substantial research suggests that the lack of linguistically matched and culturally sensitive mental health providers contributes to unequal access to mental health services for minoritized racial/ethnic groups (Chow, Jaffee, & Snowden, 2003; Aratani & Cooper, 2012; Avila & Bramlett, 2013). Because parents must navigate the mental health service sector for their children, parental perceptions that mental health service providers are not sensitive to their needs may decrease their children’s engagement in these services. Cook and colleagues (2013) found that community supply of mental health providers was related to the use of mental health services, particularly for Latin American and African American groups.

Racial/ethnic disparities in access to and engagement in mental health services may be partly attributable to the socioeconomic status of minoritized families. For example, Chow, Jaffee, and Snowden (2003) found that neighborhood poverty interacted with race/ethnicity to create disparities in utilization of mental health services among African, Latin, and Asian Americans. Specifically, individuals in high-poverty areas were more likely to use emergency and inpatient services and to have coercive referrals. In a study of the use of specialty mental health services, Alegría and colleagues (2002) found that Latin Americans from low-income backgrounds were less likely to receive specialty mental health services compared with White individuals with similar income status. On the other hand, nonpoor African Americans were less likely than their White counterparts to receive specialty mental health care. In their proposed research agenda for improving minority children’s access to mental health care, Alegría and colleagues (2015) suggest that racial/ethnic disparities be examined in conjunction with disparities in socioeconomic status to increase understanding of and capacity to promote access to and utilization of mental health services among children from low-income and minoritized groups.

Positive Socialization and Identity Formation

Children are attuned to race from an early age. Racial identity formation is a complex and relational process that develops through stages (Tatum, 2017). By age 3 months, infants demonstrate a preference for faces from their own racial/ethnic group (Kelly et al., 2005) unless regularly exposed to other ethnic groups (Anzures et al., 2012), a phenomenon not seen in newborns. Preschool children develop a sense of “race constancy”—the idea that race is a permanent part of their identity. Preschoolers also

develop implicit preferences and adopt racial stereotypes. By the start of kindergarten, children demonstrate implicit racial attitudes of the dominant society (McKown & Weinstein, 2003) and “in-group” preferences (Dunham, Baron, & Banaji, 2008). Research indicates that racial bias in the perception of others’ pain emerges as early as age 7 and is strong and reliable by age 10 (Dore et al., 2014). Adolescents begin to incorporate racial and ethnic identity more formally into their self-concept.

Racial socialization involves actively communicating with children and youth about experiences informed by race and racism, and may buffer racial trauma. Strategies for racial socialization, which includes opportunities to explore cultural pride in combination with preparation for addressing bias, have been shown to be successful (Anderson & Stevenson, 2019). In addition to racism, colorism—prejudicial or preferential treatment associated with skin tone (Walker, 1983)—can impact family processes (Landor et al., 2013), as well as experiences of discrimination and the ways in which parents racially socialize their children. As with racism, social hierarchies associated with skin tone that elevate lighter-skinned above browner-skinned individuals can lead to microaggression and discrimination and serve as a source of traumatic stress (Landor & McNeil Smith, 2019).

REDUCING OPPORTUNITY GAPS IN MENTAL HEALTH IN EARLY CHILDHOOD

Because of the myriad mechanisms that lead to opportunity gaps in mental health among young children, a multifaceted approach to these disparities is warranted. Dodge (2018) advocates for a comprehensive system of care for young children and their families that addresses the individual needs of children and their families at multiple levels of risk. In this framework, programs would incorporate preventive services at the primary level (preventing the onset of mental health disorders), secondary level (intervening for those at risk of a disorder), and tertiary level (mitigating the outcomes of mental health disorder). Similarly, preventive services would include universal (population-wide), selected (targeted toward a high-risk group), and indicated (provided based on a diagnosis) approaches.

Overall, a comprehensive approach is critical to address opportunity gaps in mental health for children from low-income and minoritized backgrounds. Fusar-Poli (2019) argues for the use of such an approach during childhood as a means of improving adult mental health outcomes. Robinson and colleagues (2017) advocate for the integration of relationship-based prevention and intervention services during the early childhood period. They emphasize collaboration across child-serving programs, utilization of data, and a public health approach to integrating systems to support child mental health. A large and growing body of evidence is available to guide

social-emotional learning programs for children (e.g., the Incredible Years, Second Step, Fast Track).

Although Butler and Rogers (2019) highlight the lack of attention to mental health disparities in childhood, strategies have been developed at multiple levels for addressing the opportunity gaps that lead to these disparities. Many of these strategies are incorporated in Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health), the federal initiative designed to promote the mental health and wellness of young children from birth to age 8 (Goodson et al., 2014). Consistent with Dodge’s (2018) comprehensive approach, the Project LAUNCH framework calls for a multipronged approach to improving the mental health and wellness of young children, including screening and assessment, incorporation of behavioral health in primary care, mental health consultation in ECE and schools, enhanced home visiting, and family strengthening. The framework specifies that these strategies should be implemented with attention to workforce development, public awareness, systems integration, and evaluation.

In addition to promoting children’s physical, social, emotional, cognitive, and behavioral development, Project LAUNCH focuses on addressing risk and protective factors at the individual and community levels. By targeting impoverished communities, this initiative is designed to improve access to and engagement in mental health and other services among children from low-income families. Additionally, it is designed to reduce racial/ethnic health disparities by implementing strategies to increase access, service use, and outcomes among young children from minoritized families.

Preliminary findings, based on a cross-site implementation study and state-level studies, suggest that Project LAUNCH has had a positive impact on providers, parents, and children (Goodson et al., 2014; Molnar et al., 2018). Specifically, providers reported increased knowledge of children’s socioemotional development and of services for children with behavioral problems, as well as increased utilization of mental health consultation. Additionally, parents reported positive perceptions of the helpfulness of programs for their families, their parenting skills, and their children’s development. Given these preliminary findings, the framework for Project LAUNCH can be useful in devising an overall strategy for addressing opportunity gaps in young children’s mental health. In what follows, we address specific strategies incorporated in the Project LAUNCH framework, including those relevant to screening and assessment, family strengthening, home visiting, early childhood mental health interventions, and integration of services into other child-serving sectors (i.e., ECE, schools, and primary health care). In this discussion, we consider the empirical evidence supporting the effectiveness of these strategies in addressing opportunity gaps in the mental health arena for young children from minoritized groups and families with low socioeconomic status.

Screening and Assessment Strategies for Reducing Opportunity Gaps

Evidence demonstrates an opportunity gap in screening and assessing children for mental health diagnoses. The Department of Health and Human Services (HHS) has proposed “increasing the proportion of children with mental health problems who receive treatment” as one of its Healthy People 2020 objectives (Healthy People 2020, 2020). Given the high rates (Halfon & Newacheck, 1999; Bitsko et al., 2022) and increasing prevalence of childhood behavioral and developmental conditions (Pastor & Reuben, 2008; Kogan et al., 2009; Blumberg et al., 2013; Bitsko et al., 2022), promptly identifying and treating these conditions is important so that children’s functional outcomes can be maximized. In addition, since long-term treatment of childhood behavioral and developmental conditions is expensive (Jacobson & Mulick, 2000; Swensen et al., 2003; Pelham, Foster, & Robb, 2007) intervention in early childhood has the potential to yield large cost savings (IOM & NRC, 2000).

Racial, ethnic, and language disparities are seen in the diagnosis and treatment of early childhood behavioral and developmental conditions. For instance, compared with other children, African American and Latino children are less likely to be diagnosed with an ASD, and are more likely to be diagnosed at older ages and with more severe symptoms (Croen et al., 2002; Mandell et al., 2002, 2009; Palmer et al., 2010; Fountain, King, & Bearman, 2011; Pedersen et al., 2012). Likewise, Black and Latino children are less likely to be diagnosed with ADHD and are less likely to be treated with a stimulant medication once diagnosed (Bussing et al., 1998, 2003; Pastor & Reuben, 2005; Stevens, Harman, & Kelleher, 2005). Table 5-1 summarizes recent peer-reviewed studies of diagnostic disparities in ASD and ADHD, two common early childhood developmental conditions. Similar disparities exist in the areas of overall developmental risk (Stevens, 2006), depression and mental health disorders (Chabra, Chávez, & Harris, 1999; Chabra et al., 1999; Zimmerman, 2005), use of psychotropic medications (Leslie et al., 2003), and use of mental health services (Garland et al., 2005). These racial and ethnic disparities deserve increased attention given recent demographic trends: census estimates suggest that the U.S. population younger than age 5 is approximately 50% racial/ethnic minority, and some states are now “majority minority” for children (Frey, 2018; Jensen et al., 2021).

Many of these disorders are identified through the pediatric medical home and at school by either a teacher or school nurse. Developmental surveillance and standardized screening are critical. Standardized developmental screening as recommended by the American Academy of Pediatrics is offered during specific times in a child’s series of well-child visits, and if necessary, referral to therapeutic services takes place after those screening

TABLE 5-1 Racial and Ethnic Differences in Diagnosis Rates for Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD)

SOURCE: Zuckerman et al., 2014.

tests. Despite these recommendations, however, recent studies have shown that Spanish-speaking Latino parents and Black parents are less likely to be asked by a provider about their developmental concerns, a difference that persists even when their child is at high risk of a developmental disorder (Zuckerman et al., 2009; Guerrero, Rodriguez, & Flores, 2011). In addition, developmental assessment and therapy may be poorly covered by insurance, making care unaffordable to many minority families (Markus et al., 2005). Even if available, specialty mental health services often are not located where minority children live. Sturm, Ringel, and Andreyeva (2003) found that geographic disparities in mental health care account for many apparent differences in mental health utilization according to race/ethnicity (Sturm, Ringel, & Andreyeva, 2003). Minority families may also have difficulty accessing services because of financial, transportation, or child care issues (Zuckerman et al., 2013).

Parent Beliefs about Child Development, Behavior, and Use of Mental Health Services

Many evaluations of a child’s mental or developmental status begin with a parental concern, and racial/ethnic and cultural variation in parental concerns may affect whether and for what reason a child receives a developmental and behavioral evaluation. Several studies have found that parents’ differing understandings of the limits of typical child behavior may impact their perception of specific developmental and behavioral problems and result in different rates of utilization of mental health care (Zuckerman et al., 2013, Table 2). For instance, in a large survey of parents of youth with identified mental health problems, Yeh and colleagues (2004) showed that African American, Asian/Pacific Islander, and Latino parents were less likely than non-Hispanic White parents to view emotional/behavioral problems as having a mental health basis (Kinser et al., 2018), a view that is associated with lower rates of use of mental health services (Pachter & Dworkin, 1997; Bornstein & Cote, 2004). Moreover, because of cultural beliefs, historical factors, and long-standing mistreatment of minorities by health care and educational systems, some parents may be less likely to feel that there is value in interacting with those systems to obtain developmental and behavioral treatment for their children. Indeed, parents from minoritized populations may be more likely to distrust the health care system in general (Yeh et al., 2004) and mental health treatment in particular.

Additionally, many families worry about the stigma associated with seeking mental health services, a concern that has been linked with a lower likelihood of attending mental health appointments. This stigma stems from a variety of misperceptions, including parents’ belief that mental health treatment is ineffective or unhelpful (Atkins et al., 2006; García,

Méndez Pérez, & Ortiz, 2000; McKay & Bannon, 2005). In a survey of 235 low-income families of school-age children, Richardson (2001) found that African American parents were twice as likely as White parents to expect disapproval from family members and to be embarrassed with respect to seeking mental health care for their children, twice as likely to perceive mental health professionals as untrustworthy and disrespectful, and three times as likely to expect poor care (Bussing et al., 1998).

Other studies have shown that cultural differences have important implications for families seeking and attending care. In particular, Latino and other minority parents do not bring their children for care because they feel that providers fail to understand cultural differences (Kummerer, Lopez-Reyna, & Hughes, 2007), and when surveyed, have expressed the view that providers have negative attitudes toward minorities or treat minority families poorly (Guarnaccia & Parra, 1996). Many of these views are likely rooted in lived experiences in which the mental health system has not performed as well for minority and other underserved families as for their White counterparts (Yeh et al., 2005; Zimmerman, 2005).

Strengthening Families’ Work Supports to Reduce Opportunity Gaps

The first few months after childbirth is a period in which mothers need time away from work to recover physically and bond with their infants. Consistent and sensitive parent–child interactions and routines provide the scaffolding for infants’ emotional regulation, attachment, and brain function, which in turn lay the foundation for the subsequent development of social, cognitive, and language skills in early childhood (IOM & NRC, 2000). Beyond infant bonding and caregiving, fathers need time to support mothers’ recovery (Yogman & Eppel, 2022), which includes being alert for maternal stress and depression (Kotelchuck, 2021). Parents adopting children or becoming foster parents also need time to engage in responsive caregiving and build strong connections, establish routines, and create stable environments (Center on the Developing Child, 2016). Elevated stress from family and financial changes is normal after childbirth or adoption. The concern is whether those changes turn into chronic stress, depression, and financial insecurity that adversely affect parents’ mental health and infant development (Shonkoff et al., 2012).

Children’s social-emotional development may also be affected by the onset of and care for their own or other family members’ serious medical conditions. Whether a newly diagnosed or worsening chronic condition, this health issue may require parents to be away from the workforce temporarily. Adequate time to recover from or provide care for these conditions can help decrease family stress, prevent economic hardship, improve health

management, encourage earlier treatment, and facilitate the return to work (Smalligan & Boyens, 2020).

Policies providing for paid family leave offer an opportunity for working parents to take time off from work temporarily to spend time with infants, adopted children, or foster children during a critical bonding period that sets the stage for healthy developmental outcomes across the life course. These policies also support taking leave to provide care for serious medical conditions, including inpatient services for mental health care. Paying wages when parents are temporarily away from their jobs is essential to mitigate financial stress and stabilize income during times of health vulnerability. Conversely, limited access to paid leave creates an opportunity gap for young children by limiting bonding time for parents and infants or adopted children, decreasing the time available to take care of serious health issues, elevating family stress, and exposing children to financial uncertainty, all of which can negatively affect children’s social-emotional development.

Although paid family leave policies benefit parents’ and young children’s mental health, their effects can vary. Positive effects on maternal mental health are consistent across studies. In most studies, paid leave had positive effects on fathers’ mental health and reduced fathers’ alcohol use, which may indicate less psychological distress (Lee et al., 2020). Evidence is mixed on the differential effects of paid leave on mental health by income and race/ethnicity, likely because of the diversity of study samples (with respect to geographic location and definition of eligible parents) and parents’ uneven access and take-up rates. Some studies found that paid leave had greater mental health benefits for parents and children in working families with low incomes (Bullinger, 2019) and lower maternal educational attainment (Kozak et al., 2021). Another study found greater improvements in parents’ mental health for White and middle-income parents, with Black children experiencing increased behavioral problems (Irish et al., 2021). Given that White, married, and highly educated mothers have higher take-up rates for maternity leave (Han, Ruhm, & Waldfogel, 2009), the design of programs with respect to length of leave, the extent to which wages are replaced, and whether workplaces and supervisors support leave taking will likely affect whether programs can benefit Black and Hispanic families and those with lower incomes.

Overall, research suggests that paid family leave policies are effective in improving social-emotional well-being for parents and their young children. These policies can be improved by reducing racial/ethnic disparities in take-up of leave through less restrictive eligibility criteria, higher wage replacement rates, targeted outreach, and improved administrative systems.

Home Visiting Strategies to Reduce Opportunity Gaps

Since the launch of the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program a large number of families from low-income backgrounds (more than 140,000 in fiscal year 2020) have received home visiting services through the program (Health Resources and Services Administration, 2022). Yet this number represents only a small fraction of eligible families. According to the National Home Visiting Yearbook (National Home Visiting Resource Center, 2021), approximately 17.6 million pregnant women and families with young children could potentially benefit from early childhood home visiting programs (National Home Visiting Resource Center, 2021). Of these potential beneficiaries, 23% (more than 4 million pregnant women and families) have incomes below the federal poverty threshold; 14% are Black/African American, and 23% are Hispanic/Latino. Thus, there is a clear need to expand home visiting services to prevent mental health challenges for families and their young children, an expansion that could be accomplished within the parameters of the MIECHV Program.

The key provisions of the MIECHV legislation are that HHS: (1) distribute funding to the states to provide home visiting services to eligible populations, (2) provide technical assistance to the states and programs on effective program implementation, (3) conduct formative and impact evaluations of the home visiting programs, and (4) create and implement a procedure for identifying effective home visiting models that states can select to receive funding. This latter mandate, called Home Visiting Evaluation and Effectiveness (HomVEE; Administration for Children and Families, 2022), calls for periodic reviews of interventions in which home visiting is the primary service delivery strategy to determine whether they improve outcomes in specific legislatively mandated domains, including maternal and child health; positive parenting practices and reductions in child maltreatment; child development and school readiness; family economic self-sufficiency; linkages and referrals to community resources and supports; and reductions in juvenile delinquency, family violence, and crime.

Evaluations of home visiting programs (including those that are and are not reviewed by HomVEE) have produced a rich set of findings. Most notably, the home visiting models being implemented by states and communities have a record of producing benefits for low-income children and families across a variety of domains that are relevant for the positive mental health of participant children (see Sama-Miller & Baumgartner, 2017, for a review).

Research has documented the positive impact of home visiting programs at the primary prevention level on outcomes related to global parenting and maltreatment (see Table 5-2 for examples).

TABLE 5-2 Outcomes of Interest for Home Visiting Programs at the Primary Prevention Level

Programs at the secondary prevention level (e.g., Healthy Families America) have shown reduced maltreatment (DuMont et al., 2011; Lee et al., 2018), more positive parenting practices (e.g., LeCroy & Krysik, 2011), improved home environments, and decreased violence in the home (LeCroy & Lopez, 2020). Compared with primary-level programs, secondary-level programs tend to be more intensive in content and format, briefer in duration, and more experiential (e.g., using active coaching and/or video feedback to promote improved parenting). Evaluations of such programs have highlighted numerous benefits (see Table 5-3 for examples).

Tertiary-level home visiting programs are typically therapeutic and are targeted at children and families that display mental health challenges. Some of these programs are relationship based, with providers using nurturance and reflection to improve parent–child interaction, as well as parent and child functioning. Evaluations of relationship-based programs have documented:

• increases in secure attachment and decreases in disorganized attachment among maltreated children (Child Parent Psychotherapy: Stronach et al., 2013), and reductions in behavior problems and trauma-related symptoms (Lieberman, Ghosh Ippen, & van Horn, 2006); and

TABLE 5-3 Outcomes of Interest for Secondary-Level Home Visiting Programs

• decreases in parental stress, maternal psychopathology, and child externalizing behavior problems (Child First; Lowell et al., 2011).

Other home visiting programs may have a parent management orientation and coach parents to alter negative interaction patterns with their children. Evaluations of such programs have shown reductions in disruptive child behavior, dysfunctional parenting, parental distress and relationship conflict, negative parental attribution for children’s misbehavior, and unrealistic parental expectations (Triple P; Prinz et al., 2009; Sanders et al., 2014).

The legislatively mandated impact evaluation associated with MIECHV—the Mother and Infant Home Visiting Program Evaluation (Michalopoulos et al., 2019)—found that four major home visiting programs (Early Head Start, Healthy Families, Nurse-Family Partnership, and Parents as Teachers) improved participant children’s ecological contexts compared with those of their nonparticipating counterparts; benefits included improved quality of the home environment, reduced frequency of psychological aggression toward the child, fewer emergency department visits, decreases in mothers’ experience with intimate partner violence and increases in mothers’ use of domestic violence services, and reductions in parental depression and stress. Consistent with the literature on home visiting, most of these benefits accrued to families. However, one child outcome finding was related to child mental health: that children enrolled in home visiting programs compared with their nonparticipating counterparts had fewer behavioral problems. Notably, all the positive outcomes found in this evaluation were similar across a range of family characteristics, including race/ethnicity.

Although there has been an increase in services for young children at all three prevention levels—primary, secondary, and tertiary—research suggests that opportunity gaps exist at each of these levels for children from racially/ethnically and socioeconomically marginalized backgrounds. Thus, the need is great for scholars, policy makers, and practitioners to devote particular attention to reducing opportunity gaps for young children and families across systems designed to address their mental health needs.

Program Strategies for Reducing Opportunity Gaps in Early Childhood Mental Health

Mental health programs are another set of interventions designed to reduce the opportunity gaps and disparate mental health outcomes experienced by children and families from racially/ethnically and socioeconomically marginalized populations. The goal of infant and early childhood mental health programs is to foster the optimal social-emotional functioning of young children, specifically regarding the development of positive relationships with adults and peers, the expression and regulation of emotions, and the creation of a solid sense of identity and autonomy. These foundational social-emotional processes may prevent the emergence of mental health problems in infancy and early childhood, as well as later in development.

Many scholars and policy makers have decried the lack of a comprehensive mental health system for children and families (Bringewatt & Gershoff, 2010; Cummings, Wen, & Druss, 2013). Extant mental health services are fragmented with respect to the provider agencies and funding sources. Nonetheless, there has been a robust response to the need for

mental health interventions for young children. Like home visiting programs, interventions in the infant and early childhood mental health arena can be categorized as primary, secondary, or tertiary, in accordance with the Pyramid Model for promoting social-emotional competence in young children (Hemmeter, Ostrosky, & Fox, 2006; Hemmeter et al., 2016). In this model, primary interventions promote children’s positive social-emotional functioning through universal supports such as nurturing and responsive relationships and high-quality supportive environments. Secondary interventions are designed to prevent the onset of mental health challenges by providing targeted social-emotional services such as explicit instruction and supports for children at risk for mental health difficulties. Finally, tertiary strategies are used to intervene with children already displaying symptoms of mental health difficulties, as exemplified by intensive treatment, skill-building, and family-centered interventions. Evidence suggests that children in Pyramid Model classrooms have improved social skills and reduced challenging behavior (Hemmeter, Ostrosky, & Fox, 2006; Hemmeter et al., 2016).

Building on the Pyramid Model and other similar models, the Center of Excellence for Infant and Early Childhood Mental Health Consultation (IECMHC) provides consultation to programs, classroom staff, and families (Duran et al., 2009; Brinamen, Taranta, & Johnston, 2012; Ash, Mackrain, & Johnston, 2013). At the program level, IECMHC consultants collaborate with administrators to develop policies and procedures (e.g., disciplinary policies, communication strategies, professional development opportunities) that promote children’s social-emotional competence and a positive climate. IECMHC consultants support teachers in classrooms in the use of positive behavior supports and strategies for managing their classrooms and addressing the needs of specific children. IECMHC consultants may also collaborate with teachers and parents to create supports for children already showing challenging behavior, which may result in fewer child suspensions and expulsions.

A growing evidence base is documenting the effectiveness of IECMHC at the child, teacher, school, and family levels (Brennan et al., 2008; Perry et al., 2010; Hepburn et al., 2013; Substance Abuse and Mental Health Services Administration, 2014; Center of Excellence for Infant & Early Childhood Mental Health Consultation [IECMHC], 2020). Studies have shown that IECMHC consultations lead to improved social-emotional competence and reduced behavior problems among participant children. IECMHC is also associated with improved teacher–child relationships and classroom climate. Participating teachers also have less stress and better skills in teaching social-emotional lessons. One study found that participation in an IECMHC program attenuated the association between teacher depression and child expulsion (Silver & Zinsser, 2020). At the school level, IECMHC

has led to lower suspension and expulsion rates, less teacher turnover, and better staff interactions. And parents participating in IECMHC displayed better relationships with their children and missed fewer work days.

One study explicitly examined whether IECMHC programs in a state reduced racial/ethnic disparities in teacher beliefs and discipline policies in preschool (Shivers, Faragó, & Gal-Szabo, 2022). Examining change over the course of a year, the authors documented a strong decrease in conflict scores for teachers and African American children and a trend toward lower risk of expulsions for African American boys over the course of IECMHC consultation. Overall, these findings suggest that disparities in mental health outcomes and the sequelae of these outcomes (e.g., suspension, expulsion) can be reduced by IECMHC programs (Center of Excellence for IECMHC, 2020; Shivers, Faragó, & Gal-Szabo, 2022).

As noted previously, research shows that children from minoritized and socioeconomically disadvantaged communities are more likely to display mental health difficulties and challenging behavior relative to their White and better-resourced peers (Shivers, Faragó, & Gal-Szabo, 2022). Yet they also have far less opportunity to participate in child-serving settings that utilize the models discussed above or in school-based, clinic-based, and community-based mental health supports in general (NRC & IOM, 2009; Alegría, Vallas, & Pumariega, 2010; Atkins et al., 2017). Overall, there is evidence that children and families from minoritized and low-income communities have a lower likelihood of engagement in high-quality mental health services (Hodgkinson et al., 2017; Rodgers et al., 2022).

Specific to early childhood mental health care, scholars have called for increased attention to young children in need of mental health care (Robinson et al., 2017). Although the previously discussed Pyramid and IECMHC models have often been implemented in Head Start and child care programs that serve children from minoritized and low-income communities (Corso, 2003; Fox & Hemmeter, 2009), these models need to be expanded so they can benefit more children, families, teachers, and programs in these communities. Important as well is to adapt these models to meet the specific cultural and community needs of participant children and families, including by hiring providers that reflect the community’s racial/ethnic composition (Cappella et al., 2008).

School Nursing to Reduce Opportunity Gaps in School

Strengthening school-based mental health systems and supports could help in addressing the growing mental and social-emotional health challenges seen in young children (Johnson, 2017; Kodzis, 2021). School nurses stand at the intersection of health and education, of supports needed to reduce barriers to learning and promote healthy children, families, and

communities. They have a broad scope of practice and offer services ranging from screening tests to care for life-threatening allergy and asthma events. School nurses ensure that all children have access to appropriate educational opportunities regardless of their state of health. To this end, it is essential for their referral options to include comprehensive school mental health systems as well as primary care providers, mental health specialists, telemedicine, and school-based health centers (Centers for Disease Control and Prevention, 2018; National Center for School Mental Health, 2019). School nurses and school-based health clinics have a foundational role, not only providing direct services for students with health problems but also promoting the health and well-being of the communities in which they live and serve. Indeed, according to the National Academies (2019), programs that engage children and families, especially those of lower socioeconomic status, and the community can best achieve positive health outcomes.

School nurses are responsible for the health and wellness of 56 million students. Their role includes detecting illnesses early, managing chronic conditions, providing mental health services, and monitoring outbreak-related illnesses (i.e., flu, RSV, COVID-19). As noted above, the need for mental health services has grown tremendously among young people, especially during the COVID-19 pandemic. Prior to the pandemic, about one-third of student health visits to school nurses were related to mental health. As previously noted, students from minoritized populations face more barriers to accessing mental health treatment relative to other groups, and structural racism can exacerbate these conditions. It is possible that school nurses can help overcome many of these barriers and play a vital role in increasing access to health care, advancing health equity, and keeping children in school. It is important to note in this connection that funding for school nurses has increased recently, including via the Coronavirus Aid, Relief, and Economic Security Act in 2020 and the Build Back Better Act in 2021.

Behavioral and mental wellness is essential for students to be healthy, safe, and ready to learn. As noted, the COVID-19 pandemic took a tremendous toll on children’s mental health, in line with the general need for enhanced monitoring of children’s mental health during public health crises (Leeb et al., 2020; see Box 5-1). The loneliness and social isolation imposed by disease mitigation measures has been shown to predict mental health problems for up to 9 years postevent (Loades et al., 2020). School nurses are frequently the first to identify and address students’ mental and behavioral health concerns and connect them and their families with systems of support. In collaboration with the interdisciplinary education team, they can provide critical links to prevention, early identification, intervention, and referral for behavioral/mental health concerns (Immerfall & Ramirez, 2019). Appropriate funding mechanisms and alignment of incentives is necessary to support these services in school-based settings. Since 2014, all

states have been able to bill Medicaid for school nurse services, but only a handful have taken advantage of this funding source, in part because of the complicated billing process (National Academies, 2021). Expanding Medicaid coverage for school nursing services offers an opportunity for children to have greater access to health care and preventive health services.

CONCLUSIONS

Families with children aged 0–5 have no universal system of community care to support their children’s social-emotional learning, mental health, and well-being, and access to quality care in this domain can vary significantly across communities. For families with fewer resources, accessing care can be particularly challenging. The lack of a universal system means that families are on their own to identify their young children’s needs and find resources to address those needs and support their children’s healthy development. As a consequence, well-resourced and advantaged families

are more able to access those resources, while the gaps in opportunities to support young children’s social-emotional development grow. This gap in the earliest years of life stands in contrast with the universal education as well as support for specialized needs in learning, nutrition, health, and social-emotional well-being provided by the K–12 system.

Access not only to mental health intervention but also to mental health promotion and prevention services is critical to parents, caregivers, and children. In many care settings, however, a lack of culturally informed and linguistically matched care can exacerbate inequalities for marginalized groups. Well-implemented universal programs such as home visiting and social-emotional learning approaches in ECE and school settings can improve social-emotional outcomes. In addition, policies that support the mental health and well-being of parents can improve outcomes for children. Access to paid family leave, in particular, gives parents opportunities to bond with their young children and enhances their ability to address serious health issues while decreasing family stress and financial uncertainty, all of which is particularly important in the early years, a critical period that can affect healthy development across the life course.

Many of the systems in the United States that are responsible for children lack coordination and interoperability. Many families—especially those experiencing poverty, job insecurity, or health issues—interact with multiple service sectors, such as health care, mental health care, child care, education, job training, substance abuse programs, and housing agencies that work independently of one another. They do not work together to coordinate services for children and families; rather, each agency has its own eligibility requirements, service providers, and practices, creating a burden on families and providing inefficient, duplicative, and siloed services.

Active policies and support for accessing proven programs is necessary to help all children thrive socially and emotionally and to eliminate centuries-old inequities in opportunities that are responsible for disparities in outcomes in this realm. Although there are many promising practices that can help close this opportunity gap, unequal access to services and resources that promote positive social-emotional development and well-being remains a barrier to promoting equitable outcomes for young children.

REFERENCES

This page intentionally left blank.