Exploring child mental health concerns with parents

What is the aim of this resource?

This resource aims to provide CHNs with some practical strategies they can use to:

• understand issues which may impact on a child’s mental health
• raise their concern about a child’s mental health with the family
• explore and gather more information about this concern
• determine the family’s level of concern and their readiness to address the issue
• develop the family’s concern on issues impacting the child’s mental health
• set a goal with the family around their child’s mental health; and
• explore options to address the concern with the parent.

Child health nurses possess extensive knowledge, skills and experience in child development and working with parents. Some information in this resource will be familiar to many nurses, while it will be new for others.

This resource covers the steps child health nurses can follow to understand concerns they have about a child’s mental health. It also explores the actions parents can take to support their child’s mental health. Following each step may be important to maintain engagement with some parents, particularly those more likely to disengage. However, nurses may find that not all steps are required when working with highly engaged and motivated parents. Nurses’ experience and clinical judgment should be used throughout these steps.

This resource will not cover:

• how to engage and build relationships with families
• the practice principles and frameworks nurses use to guide their work
• infant and child development
• the importance of the early years and factors that influence children’s wellbeing
• how to rule out physical explanations of behaviour/signs of potential child mental health issues; or
• how to make an effective referral to other services or practitioners.

If you wish to learn more about these areas, please refer to the resources listed at the end of this paper.

This resource is also not intended for nurses to diagnose child mental health issues; or to be responsible for providing interventions for children with severe mental health issues.

^1. ‘Child health nurse’ refers to nurses working with families and children from infancy through early childhood. This includes maternal, child and family health nurses.

^2. The term ‘child’ refers to all children aged 0-5 years, as per the scope of work undertake by child health nurses.

^3. The term ‘parent’ refers to the adults in children’s lives who undertake the parenting/caregiving role. This includes foster carers, grandparents, extended family, and adoptive parents.

There will be times when you have identified a general concern about an infant/child’s mental health, but are unsure whether it’s concerning enough to raise with the family. In this case, asking the family some questions about themselves, their child and how things are going for them is helpful.

Exploring the parents’ views on how their child’s social and emotional development is progressing

This includes the child’s:

• relationship with the parent/s
• relationships with others
• emotional responses
• interests; and
• ability to respond and settle into age-appropriate routines and experiences.

There are many questions you could ask families to learn more about the child’s development. Some examples include:

• ‘What grabs and holds your child’s attention? What are they interested in? How do you know that your child is interested in something or someone?’
• ‘What do you and your child enjoy doing together? How often do you get to do these things together?’
• ‘When is your child calm and content? What do they do/say to show you they are calm?’
• ‘When does your child become upset? What does that look like? How long are they usually upset for?’
• ‘How do you usually respond when your child is upset/angry/frustrated?’
• ‘What this experience like for you? What do you think it is like for your child?’
• ‘How does your child respond when there are changes to their routine?’
• ‘How does your child respond to others in the family?’
• ‘What’s it like for your child when your family or friends come over?’
• ‘Who does your child get along well with?’
• ‘How would you describe your child to someone who doesn’t know them?’
• ‘Have there been any changes or backward steps (regressions) in your child’s development? For example, in their skill development, physical development or social/emotional development?’

Your aim here is to recognise and explore anything that may be out of the range of ‘normal’ development. You will then raise this with the parent at the next step.

Exploring the main stressors and worries that impact on the child’s development and wellbeing

The questions you ask here are based on:

• the child’s age
• the parent’s experience and parenting stage; and
• what you may already know about the family.

Your questions will depend on whether you’re working with a first-time parent, someone who already has children, or a parent who has experienced the loss of a pregnancy/child.

As a general rule, you are interested in finding out about:

• how the parent is experiencing their current stage of parenting – whether that is with a newborn or a three-year-old
• changes the family has experienced that may impact on the child’s wellbeing
• the level of support the parent has:
  • Information – ‘Where do you look for parenting advice or ideas?’ ‘When you have parenting questions, who do you talk to?’
  • Practical – ‘Who can help you with daily routines or when your parenting circumstances change? For example, who can help with getting the baby to sleep, kids to school, cooking meals, shopping or getting to appointments?’ ‘Who would you call if one of the kids got sick and you needed to take them to the doctor?’
  • Personal/emotional – ‘Who can you talk to when things are tough and you just need someone to listen?’
• any financial worries or stressors the parent/family is facing
• the impacts of any physical or mental health issues the family is experiencing
• any worries the parent has about other things happening in their life; and
• their ways of coping with stress and worries.

Example questions you could ask include:

• ‘You’ve been home from hospital for about six weeks now. How are things going for you? Is parenting what you expected it to be? How are things different?’
• ‘How are things at home between you and your partner/the people you live with?’
• ‘If more support was available to you, how could it help? What would it be most useful for?’
• ‘Besides caring for your children, what else is important to you?’
• ‘How are you managing financially at the moment?’
• ‘How are you getting to appointments?’
• ‘What are the main things on your mind right now?’

Exploring the family’s strengths, including their skills and their strategies for coping with challenges and stressors

It’s important to learn about a family’s strengths and skills, as they can give you an indication of how the family is currently coping. These understandings can also provide useful information about how the family may address a potential child mental health concern.

You might ask the parent:

• ‘How did you manage this when your other children were this age?’
• ‘What has helped when you have felt worried at other times?’
• ‘How do manage to stay cool when the kids are fighting?’
• ‘You’re managing to get the twins to school every day AND feed an infant. How do you manage to fit all of that in?’

Through the duration of your work, you will notice and recognise the strengths and skills of families. Sharing these observations with families has a big impact, especially as parents rarely receive any positive messages about their parenting.

• ‘I can see by the sensitive way you respond to your children, that it’s important to you that they know you’re there for them.’
• ‘When you rub your child’s back like that, their body relaxes. I think they really like it when you comfort them like that.’
• ‘When you look at what your child is showing you, you’re letting them know that you’re attentive and care about what they’re interested in.’

Exploring resources and supports for the family

Families who have access to the right supports when they need them do better than families who are socially isolated and lacking in support networks. If you don’t know already, ask questions about the parent’s:

• access to informal supports, such as from their partner, extended family, neighbours, friends and community
• knowledge of where to get information if they need it; and
• access to formal supports, such as a regular GP, counsellor or other health professional.

These people are potential allies for parents, and can help them to enhance their child’s social and emotional development.

Following this initial conversation, it may be clear that there is at least one issue for further exploration. Alternatively, you may no longer be concerned and feel there is no need for extra support.

If you are concerned about a child’s mental health, seek the parents’ views on your specific concern before offering advice or making attempts to refer the family to another service.

In this stage, you’re gathering information that helps you decide on next steps, rather than obtaining a comprehensive history of the problem or issue.

Following these steps can help:

Step 1: Tell the family what you’re concerned about, assuming responsibility for the concern.

‘You mentioned something earlier that I’d like to ask a bit more about. You said that Luke is having a hard time adjusting to the early learning centre – he’s refusing to get in the car in the mornings, screams all the way to the Centre, sometimes throwing things in the car, and won’t let go of you when you arrive at the Centre.’

Step 2: Seek the parent’s initial ideas and thoughts about the concern you’ve raised.

‘Is that right? Have I missed anything?’

Step 3: Seek more information to explore the concern.

Ask questions about your concern to determine how often it occurs, how long it has been happening and the impact it has on the child and family. There are two reasons for collecting this information:

1. Encouraging the family to reflect on their child’s social and emotional wellbeing and mental health.
2. Capturing information that will help you and the parent to decide on any next steps.

You are interested to know about:

• Frequency (times per day/week): ‘How often does this happen? When does this problem not happen? What are the exceptions?’
• Duration (persistence of problem): ‘How long has this been happening? When did this start? Has it always been like this?’
• Severity (impact): ‘How much of an impact does this have on the child? How much does it impact on others?’
• Child’s experience: ‘How do you think your child is feeling during these times? What is it like for your child when this happens?’
• Family experience: ‘How do you feel about this? What is this like for you?’

Example:

‘How does Luke respond to going to other places or seeing other people?’

‘How long has this been happening for you and Luke?’

‘Luke seems to be having an awful time going to childcare. What do you think that might be about?’

‘I’m wondering what it’s like for you each morning taking Luke to childcare. How is this impacting on your own wellbeing?’

Step 4: Summarise the information and ask the parent if they’re concerned.

While you may be concerned, the parent may not be, so it’s important to explicitly ask them.

‘You’ve mentioned a few occasions when Luke clings to you, cries and sometimes throws things. He clings to you when you drop him off at childcare, and when people visit, even close family. When you go into another room, he starts crying and goes looking for you. While children develop in their own time, most children will feel comfortable spending some time with familiar people by the time they are three. I’m wondering what you think about this. Is it something that you’re worried about?’

If the parent is concerned:

• Invite them to have a deeper conversation about this issue by moving on to the next step, Determining the parent’s level of concern and readiness to address the issue.
• Conduct a more formal/structured assessment, if the parent has already made it clear during the discussion that they want further assessment completed (see When to use screening tools later in this document ).

If the parent is not concerned:

• Use concern development strategies (provided later in this document).

If the parent is still not concerned and this is not a child protection issue, let the family know that:

• if they would like to discuss this issue again in the future, they are welcome to call or make another appointment
• you will ask them about how things are going at the next appointment/scheduled phone call.

These steps are summarised in the chart below.

Now that you and the parent share the concern, the next step is to find out how ready the parent is to act. It’s important to remember that even when people have identified a problem, they may not yet be ready to address or solve it. Some families may have many competing demands and this issue may not be the highest priority.

Use the OARS skills (described previously) to find out:

• how their life would be different if this issue was minimised/solved
• how the family and child would benefit if this issue was addressed
• the importance of addressing this issue
• the level of influence/control the parent perceives they have about this issue
• what they are doing already that seems to be making a difference; and
• the level of priority this issue has in the context of any other issues for the family.

For example:

‘You’re a little worried that Sanjeev is wetting his bed again, and it seemed to start when you separated from Sanjeev’s dad. What would it be like for Sanjeev if he was no longer wetting his bed at night? What would change for him? What would it be like for you if the bed wetting stopped?’   

‘There seems to be a few things happening for you both at the moment. Given all those other things, how important is it to you and Sanjeev that you focus on reducing the bed wetting?’  

‘What could help you feel more ready?’

Depending on how this conversation progresses, you may:

• move on to the next step, Setting a goal
• complete a screening tool
• use some of the concern development strategies listed later in this document
• come to an agreement with the family that between now and your next scheduled appointment, they will do something to learn more about the concern raised, such as noticing and keeping a record of when the issue happens (possibly using the template provided above)
• determine that now is not the right time for the family to address this issue, given other priorities, and agree to check in with them again about this at their next appointment/agreed phone call.

Once you have determined that the parent is ready to address the concern, your next step is to set a goal with the family. This goal will be focused on something that the parent will do that will enhance their child’s mental health.

Goal setting enables a parent to identify something specific they want to change. Setting goals related to the child mental health concern early on, before exploring any actions the family may take, has several benefits:

• It allows a parent to be clear around the focus of their efforts in addressing the concern.
• It can give parents a greater sense of control over their concerns and future actions.
• It helps to turn parents’ aspirations, such as ‘I want my child to be happy’, into more specific and clear actions. For example, ‘I want my child to make friends and be able to tell me what he wants’, can lead to a range of possible actions a parent might take to the reach that goal.
• It helps break down what may seem like larger concerns into achievable and manageable chunks that the parent can then act upon.
• Well-defined, achievable goals will provide both you and the parent with a clear understanding of where they are headed, enabling them to jointly review their progress.
• Goals can also motivate the parent to follow through on any agreed actions, such as assessments or referrals to other services.

To be the most useful, goals need to state:

• whose goal it is (for example, is this something a parent/carer wants to change that will improve child mental health, and is it within their control?)
• what specific behaviours you expect to see as indicators that the change is taking place (for example, a parent/carer using an enthusiastic tone and a variety of praise statements when their child does something they were worried about doing)
• when you expect to see the changes (for example, when the child is brave and does something they were worried about, such as spending short periods of time with other family members)
• how well/often it needs to be done (for example, the parent will provide opportunities for the child to spend a short period of time with close family three times per week for four weeks); and
• why this goal is important (for example, a value or importance of this goal to their child’s social and emotional development).

It’s important that both you and the family record this goal somewhere it can be referred to. If you don’t have a way of recording a goal, you could use something like the table below (see the Appendix for a template):

If you don’t have the time to explore the goal with the parent in this level of detail, there are some simple questions you can ask that will provide the basis of a general goal. For example:

• ‘We both agree that Natalie’s sleeping pattern is different to most babies her age, and it’s clear it’s having a big impact on both you and Natalie. Before talking about the different options and strategies that may help, let’s get clear on what you’re hoping for. How much sleep do you want Natalie to be getting? When and where would you like this to happen?’
• ‘Handling tantrums is really tough, particularly in public. What would you like Sabina to be doing instead? Once we know what you’d be happy with, that gives us something to aim for. Then we can talk about options.’

Once you have determined that the parent is ready to address this concern and they have identified a goal, you can collaboratively generate options that will help them achieve this goal. There is often a range of actions parents can take to address a child mental health concern, including:

• Modifying/enhancing their interactions with their child.
• Establishing/modifying their child’s environment.
• Learning more about child development.
• Building skills to respond to their child in different ways.
• Working with their early childhood education and care provider to address a concern.
• Gathering more information about how their child is developing socially and emotionally by completing assessments or screening measures.
• Talking through the concern with another professional with specific expertise, such as a paediatrician, allied health professional, etc.
• Engaging with other local community-based child and family services and activities, such as playgroups.
• Attending a parenting group such as Triple P, sleeping and settling services, etc.

The steps outlined below can help identify options that parents are likely to feel confident to pursue and that they are hopeful are going to make a difference to their child. An example table recording this information can be found at the end of this section, and a template is provided in the Appendix.

Step 1: Write down the goal (what the parent wants to be different for their child).

If you haven’t already, ask the parent some questions, such as:

• ‘What do you want for you and your little one?’
• ‘What are you hoping to achieve?’
• ‘How could things be different for (child’s name)?’

Example:

‘Before we start thinking of solutions, let’s just get on the same page about what we’re hoping these solutions will achieve. So, what are you hoping will change for Luke in how he’s getting along with others?’
‘OK, let’s write that down.’

Step 2: Ask the parent for their ideas first.

To build parents’ self-efficacy and self-regulation, it’s important to ask for their ideas before you share your own. This shows parents that you think they have important and helpful ideas that can lead to a solution. Jumping in with your own ideas first will, over time, teach parents that you have all the answers, lowering their parenting confidence and self-efficacy.

Possible questions you could ask include:

• ‘What have you tried already to solve this problem?’
• ‘How have you solved similar problems before?’
• ‘How have you solved other issues? Are those strategies you could use here?’
• ‘What would a trusted friend/family member suggest you try?’
• ‘If a friend came to you with this problem, what would you suggest they try?’
• ‘What have you tried before that didn’t work or made things worse?’

Example:

‘You’ve asked what I think you should do, and I’ve got some ideas. But before I share those, I’m keen to know what’s on your mind. What sorts of things have you tried already? What would you suggest to a friend who was facing this challenge?’

Step 3: Ask permission to share your ideas, based on:

• available evidence; and
• your experience working with other families.

Example:

‘Would it be OK if I added some strategies that have worked for other families facing a similar issue? Once we have a list of ideas, you can decide which one would work best for you and your family.’

Step 4: Use the OARS skills to evaluate each option by seeking the parent’s perception on:

Expectations – whether the parent thinks that this strategy would help/solve the problem.

• ‘How will this idea help Sara to tell you what she wants?’
• ‘Do you think this strategy could work?’

Confidence/self-efficacy – how confident the parent feels to give this strategy a go.

• ‘How confident do you feel to give this a try between now and the next time I see you?’
• ‘If you were to rate your confidence on a scale of 1–10, with one being not confident at all to try this, and 10 being very confident, how confident are you to try this strategy?’

Values – how well this strategy aligns with the family’s values and beliefs, and with the type of parent they want to be.

• ‘What would your family/partner say about this strategy? Would they be on board?’

Support – how much support they anticipate they’ll need to be successful with this option.

• ‘Who could support you to use this strategy?’
• ‘How much effort do you think it might take to give this a try?’

These options could be rated on a scale of 1–10, with 10 being the most likely option and one being the least likely option.

Step 5: Ask the parent to decide on one or two strategies, based on the evaluation above.

Write down the parent’s preferred option, keeping in mind that sometimes circumstances change, and the parent’s preferred option may not be suitable. To plan for this, ask the parent what their ‘back up’ plan is, and write that down too.

Step 6: Write down what the parent will do, and what the nurse will do.

Be as specific as you can, as this will increase the likelihood of the action being followed. The number of actions required will depend on the concern, the goal, how much you and the nurse know about the issue, and how ready the parent is to respond to the concern.  It may be as simple as:

‘I will write down how long it takes for Adam to get to sleep at each sleep time for two weeks.’

Step 7: Set the next appointment or review date.

This is a good opportunity to schedule another consultation or follow-up phone call. It reinforces the importance of addressing the concern, and your interest in how the parent and child are progressing.

Incorporating when you will complete your actions sends a message to the parent about your role and how you can support them with their concern.

The table below gives an example of how the options and decision are recorded. You can find a template of this table in the Appendix.

There may be times when you choose to develop a parent’s concern about their child’s social and emotional wellbeing or prompt them to think through the impact of not addressing the issue. You might do this when there are significant implications (though not immediate safety concerns) of the parent not addressing the issue.

The suggestions below are not intended to help you win an argument with a parent. Rather, they’re designed to help the parent to think through all the options and repercussions, ensuring they make an informed decision. Indeed, there is no place for manipulation or rhetorical questions in a collaborative approach. All questions should be asked in the spirit of genuine curiosity and interest in the parent’s views.

As part of this, it is important to be ready to be patient. If the initial approach to addressing the concern has been gentle and empathic, a parent may go away and think about it further and decide that you can be trusted to talk with more deeply about their concerns. They might also simply be alerted to something that they now observe more closely, and may be in a different place in relation to the issue the next time they talk to you.

The step before using ‘concern development strategies’ is to ask the parent why they are not concerned. Do this with openness and curiosity. Carefully listen and summarise key points fairly and objectively. Check you have fully understood. It’s important the parent feels heard and understood throughout this discussion. Listening carefully and using OARS techniques may reveal new information that casts a different light on the situation. Careful listening might also reveal misunderstandings and/or misinterpretations by the parent that are getting in the way of them thinking productively about the issue. From time to time, check whether the new information changes the parent’s stance on the issue.

Using concern development strategies

These three strategies come from motivational interviewing. Their purpose is to build a person’s motivation to act on a concern. By asking parents these questions, you’re assisting them to consider the impacts or potential advantages of addressing a concern.

Strategy 1: Explore certainty

Ask the parent to rate how certain they are that this isn’t a problem, on a scale of 1–10, with 10 being certain and one being not certain at all.

• ‘You’re not concerned that Luke has rarely spoken to anyone at the early learning centre for the past two months. You’re thinking that’s he’s just shy and he’ll come out of his shell later. How certain are you that this isn’t a concern, with 10 being absolutely certain and one being not certain at all?’

If the parent gives a rating of 10, then summarise what they’ve said and leave the door open.

• ‘So, you’re totally confident that this won’t be a big issue for Luke. Would it be OK for me to check in on you in two months’ time, to make sure that’s still the case?’
•  ‘It sounds like you’re certain that this isn’t a problem at the moment, but feel free to get in touch if things change down the track.’

If the parent gives a rating of less than 10, ask them why they didn’t rate it a 10 and explore any doubts or factors that prevented this.

• ‘OK, so you’ve rated this a 7/10. So you’re pretty sure that Luke will talk with others soon, but you aren’t 100% sure. What’s stopping you from being totally confident that things will improve?’

Once you’ve explored the parent’s reasons, consider whether there’s an opportunity to explore these factors further.

• ‘What if we could look at some information about what’s happening for children who take longer to talk, and strategies that can encourage children to talk? Would you be interested in looking at that together?’

Strategy 2: When would you become concerned?

A second strategy that can be used to develop parents’ concerns is to ask questions around what would trigger the parent to become worried about this issue. You may try asking the parent to imagine whether they would be concerned if the problem continues or gets worse. This strategy also helps identify the point at which parents would become concerned about an issue.

Strategy 3: Are there any advantages of addressing this now?

A third strategy involves exploring whether there are any advantages in acting now, even if the parent isn’t concerned (e.g. if you could stop the problem from getting worse).

Strategy 4: Find another point of engagement/link to concerns the parent does have

Sometimes it may be possible to link an issue that is not currently a concern for the parent, with another issue that they are worried about. For example, the parent may not be concerned about a child’s limited social interactions, but may be worried about the impact of the early learning provider asking for multiple meetings to discuss their child’s progress. It may be possible to engage the parent around the child’s social and emotional skills, from the perspective of the impact the issue has on other areas of the parent’s life.

The step-by-step, collaborative process outlined in this resource is more likely to achieve positive outcomes for the child and family than an assessment or referral. The actions parents take following this conversation are wide-reaching, and could include enhancing interactions with their child, setting up routines at home, seeking additional support, or following through with further assessments and referrals.

At your next contact with the family, it is important to follow up on how they went with the agreed next steps, and troubleshoot any problems they experienced.

Appendix: Templates for recording information

• e-Learning courses

Engaging with parents

Supporting parents to promote children’s social and emotional wellbeing

• Practice papers

Making the most of your first session

Sharing information with parents about children’s social and emotional wellbeing: A step-by-step approach

Why is it difficult for parents to talk to practitioners about their children’s mental health?

• Webinars

What is infant and child mental health and why is it important for all practitioners to think about?

Engaging parents and infants in the first thousand days

• Websites

Raising Children Network

Be You (Beyond Blue)

• Centre on the Developing Child. (2013). Early childhood mental health (InBrief). Cambridge: Harvard University. Available here.
• Gardner, F., Shaw, D. S. (2009). Behavioural problems of infancy and preschool children (0–5). In M. Rutter, D. Bishop, D. S. Pine, S. Scott, J. Stevenson, E. Taylor, & A. Thapar (Eds). Rutter’s child and adolescent psychiatry. Oxford: Blackwell Publishing Ltd., p. 882–893. As cited in Ryan, R., O’Farrelly, C., & Ramchandani, P. (2017). Parenting and child mental health. London Journal of Primary Care, 9(6), 86–94. Available here.
• Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137-160. Available here.
• Miller, W. R., & Rollnick, S. (2013). Applications of motivational interviewing. Motivational interviewing: Helping people change (3rd edition). New York: Guilford Press.
• Rioseco, P., Warren, D., & Daraganova, G. (2020). Trajectories of children’s social-emotional wellbeing in the Longitudinal Study of Australian Children: The role of parenting, parents’ mental health and health behaviours. (Paper produced for Emerging Minds.) Melbourne: Australian Institute of Family Studies. Available here.