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Family Systems, Communities of Care, and Mental Health

Gail L. Ensher and Melissa M. Luke, Syracuse University


This article is an excerpt from the forthcoming book, Mental Health in the Early Years: Challenges and Pathways to Resilience, by Gail L. Ensher, David A. Clark, and Melissa M. Luke with contributing authors. This excerpt includes the value of a family systems and an ecological perspective; provides an overview of social–emotional development of infants and young children; and discusses the impact of consistent, available, and responsive early caregiving relationships on early brain development and positive mental health outcomes of infants and young children.

An accurate concept of family systems needs to take into consideration multiple contexts and dimensions. Among others, the framework must reflect family histories, places where families reside, individual family membership and perspectives, resources and opportunities available to families, and frequent daily challenges. In particular, respective cultures, ethnic backgrounds, community settings, available medical and educational resources, as well as financial and other advantages and disadvantages all affect the ways in which families function as healthy integrated systems. In turn, each of these factors influences the ways in which families are able to parent their infants and young children, leading to positive mental health outcomes. Families and their young children share several universal qualities and functions; at the same time, every family system is unique. Hanson and Lynch (2013) described families in this way:

A hallmark of the American family is diversity. Families are not unitary, nor can they be narrowly defined. Across the nation, in every community—and within the heart, mind, and experience of each individual—family is personal. Our families help to define who we are and who we are not, how we view the world, how we live, and how we share lives with others. Like the individuals within them, families change over time. In the United States and elsewhere throughout the world, families share many characteristics but differ dramatically in others. (p. 1)

Previously, Urie Bronfenbrenner (1979) described similar concepts when he wrote,

The understanding of human development demands more than the direct observation of one or two persons in the same place; it requires examination of multi-persons of interactions not limited to a single setting and must take into account aspects of the environment beyond the immediate situation containing the subject. In the absence of such a broadened perspective, much of contemporary research can be characterized as the study of development-out-of-context. (p. 2)

In addition to the above concepts, it is important to recognize that “realities” for families—individually or as a whole—differ greatly, depending on the ways in which they perceive situations, events, and specific circumstances. For example, some families are private, opting not to invite special education service providers into their homes, whereas others are eager to access all help offered. Also influencing such decisions are family perceptions of the importance of early childhood education and inclusion of having a child with a disability. It is also important for professionals working with families to understand that what affects one person in the family system has an impact on all the other people. Turnbull, Turnbull, Erwin, Soodak, and Shogren (2015) drew an insightful analogy between family systems and mobiles—that is, for a mobile (i.e., family system) to be in balance, all elements need to be of equal weight and have equal attention. If one arm of the mobile is longer or has more tension than other elements, the mobile (or family system) is out of balance.

Historically, families consist of individuals who are “united” by marriage, relationships, events, and situations; however, they function with unique individuals. Ideally, there is a partnership among members of a family that facilitates cooperation, support, and a sense of community. Over time, some family functions and relationships change, whereas others remain the same—for example, children grow and leave home, parents may or may not remain together, jobs and economic situations change, families may move, or significant events transpire. With that said, the one essential and universal thread that hopefully binds families together is a nurturing, caring, and loving environment on behalf of their young children.

This central tenet underscores the concept of family-centered practices, a cornerstone of the Individuals With Disabilities Act (U.S. Department of Education, Federal Register, 2011), which was revised and approved in 2004. In particular, this legislation mandates that early intervention services for infants and young children with disabilities and special health care needs be developed and implemented within the context of the family. This noteworthy shift differs from prior provisions of service that focused primarily on the child (Beckstrand, Pienkowski, Powers, & Scanlon, 2016). This approach highlights the essential importance of family relationships for positive mental health outcomes of all infants and young children from birth to 5 years old (ZERO TO THREE, 2016). As infants and young children grow and develop, they obviously have different needs, and families thus give back in different ways, as noted in the following sections.

Benchmarks of Healthy Social–Emotional Development in the First 5 Years

Full-term newborns enter the world prepared to engage socially and emotionally with people in their immediate environment. Although there are, of course, variations in temperament, there are known behaviors and qualities that babies during the first year of life bring to the development of relationships with their caregivers; likewise, families offer critical interactions to their infants and young children. McClelland, Tominey, Schmitt, and Duncan (2017) indicated that

Social and emotional learning (SEL) refers to a broad range of social, emotional, and behavioral skills for children. We highlight three main components of SEL skills: emotional processes, social/interpersonal skills, and cognitive regulation…. The first component, emotional processes, encompasses the skills children need to manage their emotions effectively and recognize the emotions of others….The second component, social/interpersonal skills, includes behaviors that help children and adults interact positively and effectively with others….The third SEL skill component, cognitive regulation, focuses on cognitive flexibility, working memory, and inhibitory control (also referred to as executive function). (p. 34)

As we discuss in the following sections, such skills develop from birth throughout the early childhood years at home as well as in more formal preschool settings, and they now are being advocated in many public school settings as “a public health approach in the field of education” (Greenberg, Domitrovich, Weissberg, & Durlak, 2017, p. 13).

Newborns and the First Year of Life

What do newborns and infants bring? Whether breast- or bottle-fed, newborns and infants are able to make eye contact approximately 10 inches from the faces of caregivers feeding them (Clark-Gambelunghe & Clark, 2015). They recognize their own mother’s breast pads and are more communicative and expressive in response to faces and body contact, which initially elicit reciprocal interactions that continue to grow throughout the first 12 months. Sometime during the first 3 months, babies develop a social smile—a key milestone greatly anticipated by family members. As development during the first year evolves, other skills that facilitate communication and healthy social–emotional capacities emerge. For example, infants between 3 and 6 months old become mobile (capable of moving from one place to another by rolling, creeping and crawling, and starting to pull up), self-feed with finger foods, join in simple turn-taking games such as peek-a-boo and pat-a-cake, and express increasingly complex repertoires of language and understanding. As a result, circles of communication expand so that babies become more and more interactive and responsive to others.

The period between 6 and 12 months old reflects a dramatic escalation of skills and abilities across all developmental domains. Again, there is significant variability from one child to another; however, there are likewise certain benchmarks that infants typically meet by the end of the first year. These skills include sitting up independently, standing, and taking first steps so that babies approaching toddlerhood are on a more even plane with the adults in their immediate environment and beyond. The 6- to 12-month-old realizes that objects continue to exist even though they may not be within his visual space. Babies are able to localize sounds, and their ever-developing motor skills facilitate their engagement with a wider variety of toys, materials, playground facilities, and movement opportunities. In addition, the 12-month-old begins to develop refined skills for self-feeding with eating utensils and a wider range of foods.

Typically, babies between 8 and 12 months old begin to exhibit behavior known as “stranger anxiety,” at which time they show strong preferences for their primary caregivers; they may even cry when being held by familiar family members such as grandparents versus when being held by their mothers and fathers. In sum, a 12-month-old is extremely adept at expressing her likes, dislikes, and own unique temperament and personality as she interacts socially and emotionally with family members and others in preparation for the more independent, “self-assertive” toddler years.

What do families bring? Families are the greatest advocates, assets, and foundations for positive mental health outcomes on behalf of their children. Throughout the rapidly evolving developmental stages of the first 12 months, it is incumbent on parents to “read” and be sensitive to infant cues and, to the best of their abilities, respond with nurturing and loving support and caregiving. First, and most important, families (specifically primary caregivers) are the cornerstones of infant–child attachments across the life span that encompass multiple dimensions of interaction and relationships (Benoit, 2004; Bowlby, 1988).

Infants and young children do not develop well emotionally without a secure, safe, and protective foundation of support with a constant, consistent primary caregiver or parent. Research in the field of early childhood has represented years of study in which young children have experienced less-than-advantageous or adverse environments, devoid of these essential elements. In such cases, the mental health outcomes are not positive overall. Furthermore, without relationships with other key people in their lives, infants and young children experiencing this kind of toxic stress likely face lifelong trauma and consequences, which Lieberman and Soler (2013) described as a “public health emergency” (p. 4).

Healthy relationships require communication. By means of touch, eye gaze, gesture, and verbal expression, babies and their caregivers relate to one another and interact. Studies have demonstrated that there is a strong correlation between the expressive verbal abilities of toddlers and young children and the ways that primary caregivers talk to and communicate with their babies (Cates et al., 2012; Tamis-LeMonda & Rodriguez, 2014; Topping, Dekhinet, & Zeedyk, 2012). An important aspect of communication is the ways that families nurture and connect with their infants and young children through various dimensions of play (Milteer, Ginsburg, Council on Communications and Media Committee on Psychosocial Aspects of Child and Family Health, & Mulligan, 2012). Milteer et al. (2012) wrote,

Play is essential to the social, emotional, cognitive, and physical well-being of children beginning in early childhood. It is a natural tool for children to develop resiliency as they learn to cooperate, overcome challenges, and negotiate with others. Play also allows children to be creative. It provides time for parents to be fully engaged with the perspective of their child. For children who are underresourced to reach their highest potential, it is essential that parents, educators, and pediatricians recognize the importance of lifelong benefits that children gain from play. (p. e204)

Along with a safe physical space and appropriate physical care and nourishment, attachment, communication, and play are three key, multifaceted aspects of a healthy social–emotional environment for infants during the first year of life. Moreover, these elements are critical throughout the life span of the young child.

It is also important for professionals working with families to understand that what affects one person in the family system has an impact on all the other people. Photo: Justin Ray

1–3 Years Old

What does the 1- to 3-year-old bring? As the 12-month-old moves toward toddlerhood and the preschool years, the typical course of social–emotional development changes dramatically. Still closely attached to the primary caregiver, the 13- to 18-month-old shows signs of growing independence and a personal agenda, which becomes overtly manifested in the 2- to 3-year-old child. Both expressive and receptive language reach new milestones and benchmarks, facilitating wider circles of communication, understanding, and social–emotional interactions with the larger world beyond the immediate family. “No” and “mine” are familiar responses as well as substantial resistance to sharing with siblings and peers.

At 2 years old, toddlers typically can name almost any object or word that they have heard at home or their child care setting, put two words together as sentences, follow one- to two-step directions, name familiar people such as family members, identify several body parts, and understand more than 300 words. At this age, the 2- to 3-year-old can also identify mommy and daddy by name, indicate that his caregiver is at work, remember events that have just taken place, and ask repeated questions of “why.”

Full-term newborns enter the world prepared to engage socially and emotionally with people in their immediate environment.

Socially and emotionally, the emerging toddler more and more reflects evidence of her own personality, especially in response to familiar adults. From 12 to 18 months old, most toddlers can soothe themselves or be soothed within a few minutes. However, total “meltdowns” may become increasingly frequent, when agendas of others take precedence and are different from their own. As a result, transitions from child-determined, desired activities become increasingly challenging to parents to negotiate with their 2- to 3-year-old. In addition, the toddler is now capable of identifying her own age fairly consistently and naming her own gender, distinguishing between “good” and “bad” behavior (i.e., making good choices vs. bad choices), and she now shows evidence of pretend play in increasingly complex scenarios involving peers. In brief,

…as preschoolers approach their third birthdays, they typically have grown into vibrant, inquisitive, more affectionate and caring, and interactive little persons, increasingly capable of understanding the world about them, and more adept at communicating with the significant others who fill their lives and relationships. (Ensher & Clark, 2016, p. 19)

What do families bring? As 12-month-olds move into the toddler months, nearing 2 years old with a bit more independence, parental and caregiving roles likewise change. The toddler becomes more skilled at feeding himself, as well as undressing and dressing, is increasingly aware of his own feelings and the emotions of others, and is more and more capable of self-care such as putting away toys; accordingly, parents transition to assisting and facilitating rather than exclusively “doing for” their child. Engaging in play scenarios; language, learning, and problem solving; and understanding the perspectives of others continue to be important dimensions of the young child’s ever-expanding social–emotional world. At the same time, new emotional states and child agendas become prominent, requiring parents and caregivers to establish clear and reasonable behavioral limits and expectations.

Although variable across diverse ethnic and cultural groups, positive approaches of adults for guiding challenging behavior are essential determinants toward nurturing healthy social–emotional development of their young children. Eventually, the child’s primarily self-focused world of “me,” “mine,” and “no” begins to give way toward more compliance, with a less self-absorbed, more willing participation with others—skills and abilities that must be supported by loving, consistent primary caregivers of the family. In the process of occasional meltdowns, limit setting and guidance from parents can be challenging.

However, between 25 and 36 months, as the child’s abilities to make choices and understand feelings of others grow, a child’s regulation of her emotions (coupled with less impulsivity and frustrations) begins to emerge. As a result, the preschooler, nearing 3 years old, becomes more amenable to developing cooperative, collaborative skills such as turn-taking and sharing with siblings and peers. Moreover, from the family’s perspective, the importance of this developmental period of the young child is essential in preparation for the later preschool and primary- age years. Parent–child “survival” of the “terrible 2s” is an important door and pathway for social–emotional well-being, competence, and positive mental health outcomes for toddlers and young children (Ensher & Clark, 2016, p. 53).

3–5 Years Old

What do 3- to 5-year-olds bring? As young children move into the preschool years, they are still largely “compelled” by self-directed emotions; at the same time, with more adept communication and cognitive skills, they are better able to understand the differences between appropriate and inappropriate behavior, how they feel (e.g., sad vs. happy), and the feelings of others. Emotional outbursts and meltdowns are less frequent, and the 3- to 5-year-old is increasingly able to realize the consequences of his behavior. Furthermore, the preschooler may even develop a sense of humor as well as comprehending funny or silly situations. Similarly, children at this age grow increasingly able to empathize with the feelings of others.

Imaginative and pretend play is more evident, allowing the preschooler to work out social–emotional problems and conflicts; thus, the use of social stories can be a helpful means toward greater understanding of “right” from “wrong.” Although the preschool child yet remains largely egocentric, she is capable of developing relationships beyond the immediate members of her family, with the young child being eager to please. The 3- to 5-year-old still requires assistance from others; yet, day by day, he grows more independent and self-reliant in accomplishing tasks for which he exhibits great pride and pleasure. Indeed, the preschool child offers caregivers, family members, and teachers multiple, rich opportunities for “teaching” essential social–emotional skills toward positive mental health outcomes that prepare him for later, lifelong challenges. All that said, it is important to recognize the considerable diversity in social–emotional development among young children at this age in terms of temperament, socialization skills, imagination, self-regulation, and other dimensions of personality. Young children develop certain universal milestones and benchmarks; they also are wonderfully unique and very different from one another.

What do families bring? Families can help their preschoolers with their socialization and emotional development by providing them with consistency; structure; realistic expectations; reasonable opportunities to make their own age-appropriate decisions; and a loving, predictable home environment free from toxic stress and violence. Accordingly, parents need to teach their young children strategies for expressing their emotions in appropriate and positive ways to resolve conflicts constructively. Young children need to understand the consequences of their behavior and the importance of demonstrating empathy toward others. Parents must still nurture the child’s “home base” of attachment to build on the foundations of confidence and security as their sons and daughters learn to be more self-sufficient, independent little people.

Play continues to be an essential means for caregivers to foster healthy social–emotional development at this age, observing and modeling appropriate, natural behavior. Using caring guidance with simple explanations and realistic “fair” limits likely will result in happier outcomes for both parents and children. Toward this goal, the Mid-State Central Early Childhood Direction Center, located in Syracuse, New York (Menapace, LeCao, Gill, Colavita, & Zubal-Ruggieri, 2009), has offered several activities to help parents and caregivers foster social–emotional development of 3- to 6-year-olds:

  • playing in small groups to help children resolve problems,
  • reading books about feelings,
  • setting up pretend play situations that provide examples of how to play with other children,
  • having children help around the house such as cleaning up toys or helping with cooking,
  • providing opportunities to play outside with other children while keeping a watchful eye,
  • having children talk about a favorite book and ask questions,
  • encouraging children to make age-appropriate decisions, and
  • asking children how to resolve social conflict situations with other children (e.g., sisters, brothers, or friends at the house) (adapted from Landy, 2002).

In short, as preschoolers approach the end of being 5 years old, entering kindergarten and moving into the primary elementary school grades, they are

  • competent and better able to communicate how they feel,
  • better able to regulate their emotions,
  • increasingly able to relate to their peers and problem solve social situations, and
  • better prepared to meet the world outside of their immediate family.

Parents, caregivers, and preschool teachers can make all the difference as to whether and how well prepared young children are to meet these challenges!

The period between 6 and 12 months old reflects a dramatic escalation of skills and abilities across all developmental domains. Photo: David A. Clark

Developmental Touchpoints, Environmental Determinants, and Mental Health Outcomes

As noted in the discussion in the previous sections, over the past 2 decades there has been growing interest in the related issues of early brain development, environmental determinants and epigenetics, the prevention of disease, key roles of families, early education, and mental health outcomes of young children. Although educators and researchers have yet to resolve many critical issues, they now are posing questions that hold considerable promise for leading to solutions geared toward the benefit and welfare of infants, young children, and their families. Without equivocation, this new agenda of research has the potential for determining trajectories of wellness and better mental health outcomes in the future. In their discussion of the “tipping points” for developmental outcomes, Ensher and Clark (2016) wrote, “Despite the overwhelming ‘weight’ of risk indicators that may lead to future mental health problems, there are infants and young children who somehow are protected from these influences, survive, and fare better than do other children” (pp. 56–57). Moreover, Ensher and Clark (2009) noted that

Some of the differences reside in the severity of exposure to violence, the presence of a significant other who can serve to “protect” the child, the age of exposure to maltreatment, the length of time during which the child was subjected to abuse, and/or neglect, relief or removal from the violence, and child-specific characteristics. Most likely, resilience or an ability to adapt beyond adversity for more favorable outcomes ultimately will reside with the benefit of a combination of factors influencing any given child within the context of his or her family. Also, how professionals determine, and who identifies, positive outcomes and when in the lives of children those questions are examined, may vary across agencies, teachers, or those making such judgment calls. Children change. They may “look” adjusted at one point in their lives; yet, given a different set of circumstances, they may need support and intervention at another time. Thus, on the continuum of living from day to day, these are indeed difficult determinations to make. However, there are children who, in reality, do better than others do, and it is imperative to examine why and how that can be and then to translate that evidence into practice, whenever possible. (p. 281)

Families are the greatest advocates, assets, and foundations for positive mental health outcomes on behalf of their children. Photo: David A. Clark

Clearly, the constellation of determining factors extends beyond issues of child abuse, neglect, and violence. Childbirth events, congenital anomalies, family situations such as separation and divorce, educational issues, weather-related disasters, and many other physical and social–emotional factors can and do influence the short- and long-term mental health of infants and young children. The field of early childhood and special education has a long history of well-documented incidents that often lead to less advantageous mental health outcomes for infants and children younger than 5 years old. The challenge then for workers in the helping professional disciplines (i.e., pediatric–medical, educational, psycho–social, and health care disciplines) becomes how to develop and implement proactive approaches for intervention early and before cycles of toxic stress (of whatever nature) take place. In so doing, possibilities for reversing or changing the direction of lifelong illnesses might be increased, and trajectories toward more positive mental health outcomes might be enhanced.


This article discussed an ecological perspective for understanding families of infants and young children, with and without disabilities and special health care needs, and the potentials for enhancing their mental health outcomes. Discussion focused on the critical importance of consistent, responsive family relationships for positive mental health development of young children. The article briefly highlighted what caregivers and their children each bring, through positive interaction and communication, in contributing to the trajectories of positive mental health outcomes across the developmental spectrum of the first 5 years.

Key take-away points include the importance of

  • considering multiple contexts and dimensions as a framework for fully understanding families and some of the contributing influences that affect the mental health of their infants and young children;
  • the reality that complex, diverse factors and events affect mental health outcomes, start early, and have long-term consequences;
  • understanding that a wealth of research has documented many of the key variables that may contribute early to less advantageous mental health outcomes; and
  • knowing that through early interventions, professionals can facilitate positive family–child relationships and thus improve the mental health of infants and young children in the first 5 years of life. (Achieving such goals will require coordinated, collaborative efforts on the part of professionals across multiple disciplines charged with the responsibility of working with infants, young children, and their families.)

About the Authors

Gail M. Ensher, EdD, is professor of education, teaching, and leadership programs at Syracuse University. Dr. Ensher also coordinates two master’s degree programs in the School of Education and works in close partnership with the Jowonio School, a nationally known inclusive educational setting for preschool children. Dr. Ensher has been and continues to be actively involved in teaching, writing, research, and community service related to families and young children who are at risk for or who have developmental disabilities. She has authored and coauthored several books about families, infants, and young children with special needs.

Melissa M. Luke, PhD, LMHC, NCC, ACS, is dean’s professor, Department of Counseling and Human Services, and associate dean for research, School of Education, Syracuse University, Syracuse, NY. Dr. Luke is also a nationally certified counselor and a licensed mental health counselor in the state of New York. Dr. Luke’s scholarship focuses on counselor preparation and practice to more effectively respond to the needs of underserved children and adolescents, particularly lesbian, gay, bisexual, transgender, and questioning youths, and she has published extensively in the area of counselor supervision.

Suggested Citaiton

Ensher, G. L., & Luke, M. M. (2020). Family systems, communities of care, and mental health. ZERO TO THREE Journal, 40(4), 59–65.


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Cates, C. B., Dreyer, B. P., Berkule, S. P., White, L. J., Arevato, J. A., & Mendelsohn, A. L. (2012). Infant communication and subsequent language development in children from low income families: The role of early cognitive stimulation. Journal of Developmental and Behavioral Pediatrics, 33, 577–585.

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Ensher, G. L., & Clark, D. A. (2016). The early years: Foundations for best practice with special children and their families. Washington, DC: ZERO TO THREE.

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Lieberman, A. F., & Soler, E. (2013). Child exposure to violence as a public health emergency. ZERO TO THREE Journal, 34(2), 4–10.

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