Increased cooperation between preschool, CHC to identify children with mental health problems

"All three groups in our study -- nurses, preschool teachers and parents -- thought that the systematic approach works well and that the routine with questionnaires provides more knowledge about the children for both preschool and child healthcare services. However, the use of standardised questionnaires is a controversial issue among preschool teachers," says Elizabeth Fält, PhD student and district nurse, who carried out the study.

Although it is the child healthcare system's task to monitor children's health, behaviour and development, it is preschool teachers that possess much of the information needed to make a comprehensive assessment of the child. Their knowledge is not systematically utilised within child healthcare since there is no established channel for information sharing between the healthcare and preschool systems.

The ongoing study "Children and Parents in Focus" was launched in Uppsala, Sweden, in 2013. The study evaluated a method to enhance communication between parents, preschool and child healthcare, regarding children's mental health.

When the parents of all 3-, 4-, and 5-year-olds in Uppsala receive the invitation letter for the child's annual visit to the child health centre, they also receive an additional form with 25 questions. This form, the Strengths and Difficulties Questionnaire (SDQ), is widely used internationally and contains questions about the child's behaviour, emotions, and social relationships.

The parents receive three SDQ forms. If the family agrees to participate in the study, the parents each complete a separate form and take the third questionnaire to their child's preschool for the teachers to complete. The completed forms are then returned to the CHC nurse and reviewed during the child's regular visits to the CHC.

All stakeholders were in favour of the new procedure, though all stakeholders also noted some problems.

• CHC nurses think the forms are important for their assessment and constitute a good basis for a more complete evaluation of the child. CHC nurses acknowledge that they gain knowledge of the child that they would probably have missed without the form. They also feel that it is valuable to get information from both parents and preschool teachers, since they see the child in different environments that make different demands. Unfortunately, CHC nurses finds that socially vulnerable families, and families with a child where problems are suspected, refrain from completing the forms more often than other families.

• Preschool teachers want to identify and help children with difficulties and most preschool teachers think that the transfer of information using the SDQ can be a good tool for that. But the interviews also showed that the use of structured forms to assess children's social and emotional development is a controversial issue among preschool teachers.

"They argue that the use of structured (normative) forms is regarded as outdated in preschool and that such tools are contradictory to preschool's policy documents. They fear the children might be labelled and thus affected negatively in the future if they are assessed with standardised forms. Nevertheless, preschools have a responsibility to offer all children adequate support in their development and to collaborate with parents, so there is a conflict there," says Elizabeth Fält.

The preschool teachers also feel worried about parents' reactions to the preschool assessment. At the same time, they acknowledge that the information transfer benefits the preschool, as the new routine can contribute by giving the preschool a more detailed picture of each child and can result in good collegial discussions.

• Parents look forward to learning about part of the preschool's assessment at the child healthcare centre visit. They think that the forms get them to reflect on their child's situation and behaviour, which they perceive as positive. They also think that the questionnaire can lead to valuable discussions with the other parent, as the points initiate discussions they would not otherwise have. Nevertheless, parents have some concerns about how personal information is handled and used; like the preschool teachers, they are afraid that the information they provide through SDQ might have negative consequences for the child in the long run.