Behavioral Health Disorders of Early Childhood

As part of typical development, all young children (ages 1-4) have strong feelings, and sometimes feel overwhelmed.  They may show their feelings by crying, screaming, and having melt-downs. These behaviors are normal, healthy, and expected.  

It is also normal for young children to have worries and fears.  These worries may be more pronounced for weeks or months, and then fade.  Or, they may be consistent. Young children have big imaginations, and have trouble telling the difference between what is real and what is pretend.  This means they are often scared of things that are imaginary, in addition to things that are real. Common early childhood fears include: 

• Separating from parents 

• Strangers 

• Monsters 

• The dark 

• Going to bed 

• Loud noises 

Children with heart defects are more likely than others to have a diagnosis related to behavior or emotions.  However, diagnoses of emotional or behavioral disorders remain rare in young children with heart defects.    

Many doctors and psychologists wait until a child is older before they make a diagnosis of an emotional or behavioral disorder.  Diagnosing young children is hard because: 

• They are changing quickly 

• They can grow out of early challenges 

• They often cannot explain what they think or feel 

• Big feelings and mood swings are common in early childhood 

• Some diagnoses can only be used for older children and adults 

Children with complex heart defects should have a neurodevelopmental evaluation with a child psychologist when they are: 

• Approximately 18 months old 

• Approximately 3 years old 

During a neurodevelopmental evaluation, the clinician can help families to understand if their child has an emotional or behavioral disorder.  Families can ask for a neurodevelopmental evaluation from their local cardiac neurodevelopmental program, or from their pediatrician. 

Sometimes, clinicians diagnose an emotional or behavioral disorder separately from a neurodevelopmental evaluation.  Children can be tested for an emotional or behavioral disorder: 

• By their pediatrician during an office visit 

• Through an Early Intervention (EI) evaluation 

• Through a Special Education school evaluation 

• By a psychologist during a diagnostic interview 

Young children with emotional and behavioral challenges may be diagnosed with the following disorders. Some of these diagnoses only apply to certain age ranges.

Children with an adjustment disorder have an unusually strong reaction to a stressful event.  Their reaction may be more extreme than expected, or last longer than expected.  The stressful event could be: 

• A medical treatment 

• An illness or injury 

• A divorce 

• A move 

• The birth of a sibling 

• The death of a family member or pet 

• Illness or injury of a loved one

It is normal to react emotionally to big life events.  Children are expected to show feelings such as sadness, anxiety, and anger when a big change occurs. Usually, a child’s reaction seems to match the significance of the event.  Their reaction typically lessens with time. 

Children with Post-Traumatic Stress Disorder (PTSD) have experienced or witnessed a scary and unsafe event. The scary and unsafe event could be something like: 

• A medical emergency 

• A car accident 

• Witnessing the death of a loved one  

• Being the victim of violence 

• Witnessing violence in the home or community 

Children with PTSD have symptoms such as: 

• Flashbacks (feeling like they are experiencing the event) 

• Unwanted thoughts about the event 

• Avoiding experiences that remind them of the event 

• Nightmares 

• Severe anxiety 

• Hypervigilance (constantly monitoring for danger) 

• Mood changes (feeling more sad or irritable, unusual mood changes) 

Children with heart defects generally have many medical treatments.  Medical treatments are necessary, and often life-saving.  However, sometimes medical treatments can be very scary for young children.  In some cases, young children develop PTSD after a medical event.  A child may be more likely to develop PTSD if they: 

• Have medical procedures they did not expect 

• Have an emergency procedure 

• See adults acting frightened or frantic while providing medical care 

• Having an unexpected ambulance ride or helicopter transfer 

• Are awake while intubated (having a breathing tube in their throat) 

• Have painful or frightening procedures 

• Have delirium in a medical setting (feeling confused, seeing or hearing things that are not there, not being able to tell what is real) 

• Are awake but unable to move 

Caregivers should remember that young children understand experiences differently from adults. Children may be scared by parts of an event that did not scare adults.  Caregivers and therapists should carefully question children to discover how the children perceived any major medical event. PTSD symptoms can last for months or years, but can get much better with treatment.  

Children with PTSD need specialized help in order to feel better.  When they get appropriate treatment, their symptoms can improve or go away. Many hospitals have clinicians who are trained to help children with medical coping, and medical PTSD.  Clinicians may include: 

• Psychologists 

• Psychiatrists 

• Social workers 

• Mental health counselors 

• Palliative care team members 

Families should ask their doctors who might be able to help their child with medical PTSD. Each child’s treatment should be specially designed for their unique strengths and needs. Effective treatments for early childhood PTSD can include: 

• Trauma-Focused Cognitive-Behavioral Therapy 

• Play Therapy 

• Family Therapy 

• Parent Guidance 

• Medication before and during medical procedures 

As always, new medicine should be cleared with a child’s cardiologist. 

Adjustment Disorder and Post-Traumatic Stress Disorder are similar.  However, there are important differences between the diagnoses. 

Adjustment Disorder is in response to a stressful life change.  The life change can be something that most people would consider negative or positive.  For example, the life change could be starting a new school, the birth of a sibling, or the divorce of parents. By contrast, Post-Traumatic Stress Disorder is always in response to a very scary and unsafe event. For example, the event could be a medical emergency, a car accident, or witnessing the death of a loved one.  

With Adjustment Disorder, symptoms are usually temporary, and resolve with time.  The symptoms resolve more quickly with appropriate treatment.  Symptoms of Post-Traumatic Stress Disorder do not usually resolve quickly.  Children experience PTSD symptoms for at least a month, and often for months or years.  PTSD symptoms improve with appropriate treatment.  

Unlike Adjustment Disorder, PTSD can affect how children think, and how they understand their environment. For example, children with PTSD can: 

• Constantly be looking for danger (hypervigilance) 

• Believe things that do not make sense 

• Be certain that they are in danger, when they are in fact safe 

• Have flashbacks, when they feel like they are reliving the scary event 

Children with an Anxiety Disorder worry more than most children, and their worry interferes with their daily life. They may have symptoms such as: 

• Trouble falling or staying asleep 

• Getting irritated easily 

• Getting tired easily 

• Feeling “on edge” 

• Tense muscles 

• Headache 

• Upset stomach 

• Trouble concentrating 

• Being easily startled 

When a young child has an Anxiety Disorder, parents have many options for effective treatments. With appropriate treatment, children almost always get much better. Families should talk with their doctor about options to treat a child’s anxiety.  Cardiac neurodevelopmental programs can help families find appropriate therapies and providers. 

Each child’s treatment should be designed for their unique needs and strengths.  Early childhood anxiety can be treated with: 

• Therapy 

  • Family therapy  

  • Exposure therapy 

  • Parent-Child Interaction Therapy (PCIT) 

  • Play therapy 

• Parent guidance 

• Medication 

As always, new medicine should be cleared with a child’s cardiologist. 

Children with depression have a low mood for a long period of time.  They often lose interest in activities, and have trouble feeling pleasure.  Sometimes they feel hopeless.  Children with depression may criticize themselves. For example, they might say things like, “Nobody likes me,” or “I’m dumb.”

Many people think of depression as sadness.  In young children, depression can also look like being annoyed and irritable a lot of the time. Young children with depression might have physical symptoms such as: 

• Trouble sleeping 

• Sleeping too much 

• Trouble concentrating 

• Feeling very tired 

• Not eating enough 

• Eating more than they want to 

There are different kinds of depressive disorder.  Some of the types are only diagnosed in older children or adults. Young children might be diagnosed with:

• Major Depressive Disorder (MDD) means a person has overwhelming sadness, and/or is unable to feel interest or pleasure. They have these feelings for two weeks or longer. 

• Persistent Depressive Disorder is milder than major depressive disorder but goes on for a long time.  It means a person often feels sad or hopeless.  They have trouble feeling interest or pleasure.  They may feel guilty and have low self-esteem.  They have these feelings for months or years.  

• Disruptive Mood Dysregulation Disorder means a child is often angry and irritable.  They frequently have severe emotional outbursts.   

Some preschool-age children with depression talk about hurting or killing themselves.  Many children have these thoughts, but do not plan to follow through with action. Occasionally, young children with depression do hurt themselves on purpose. 

Parents should always immediately call a doctor or go to an emergency room if a child talks about hurting or killing themselves.  A doctor can help families determine whether a child’s safety is at risk. 

Young children with depression need timely and appropriate treatment.  With the right treatment, young children usually get much better. 

When a young child is diagnosed with depression, families should talk with their doctor or psychologist about treatment options.  A cardiac neurodevelopmental program can help, if one is available. Each child’s treatment should be designed to meet their unique needs. Effective treatments for early childhood depression can include: 

• Therapy 

  • Family therapy  

  • Parent-Child Interaction Therapy (PCIT) 

  • Cognitive-Behavioral Therapy 

  • Play therapy 

• Parent guidance 

• Medication 

As always, new medicine should be cleared with a child’s cardiologist. 

Children with Obsessive-Compulsive Disorder (OCD) have unwanted thoughts, ideas, or feelings that keep coming back.  These unwanted thoughts, ideas, and feelings are called “obsessions.”  In order to manage their obsessions, they feel like they have to do certain actions.  These actions are called “compulsions.”   

Very young children often have trouble explaining their obsessions or compulsions. They may just say they “need” to do something. They usually become distressed if they cannot complete the behavior.    When children have OCD, their obsessions and compulsions interfere with their daily lives. 

Families often feel complex emotions when a child is diagnosed with OCD.  However, parents should be reassured that young children with OCD can get much better with treatment. 

Families should talk with their child’s doctors to find good treatment programs in their area.  Cardiac neurodevelopmental programs can help children with heart defects and OCD, when they are available. Each child’s treatment should be specially designed for their unique strengths and needs. Effective treatments for early childhood OCD can include: 

• Therapy 

  • Cognitive-Behavioral Therapy 

  • Play Therapy 

  • Family Therapy 

• Parent Guidance 

• Medication 

As always, new medicine should be cleared with a child’s cardiologist. 

When a child has a behavioral health disorder, the whole family is affected. Treatment and healing are most effective when they happen at the family system level.   Children are happiest and healthiest when everyone in the family is also healthy: when stress levels are low, and when family members can communicate openly and lovingly.  When parents take care of their own mental health and their own relationships, they can create an environment that is consistent and calming for everyone. 

This content was reviewed by a psychologist at Boston Children's Hospital.

Developmental care is best when it is local. Families local to Boston can receive care from the Cardiac Neurodevelopmental Program (CNP), the Department of Developmental Medicine, or the Department of Psychiatry. Families from other regions can use the link below to find their local care team.