My previous blog described a childcare system built for labour force participation, not for children. It identified the gap between standards on paper and the daily conditions children actually experience. This blog asks what the consequences of those conditions are. Not the regulatory consequences. The human ones.
Mental health conditions in children under five are not rare. They are not exceptional. They are a measurable, documented reality that we continue to underestimate - and underact upon. We do not talk about mental health and babies in the same breath. We should.
A major international meta-analysis, cited by the Royal College of Psychiatrists in its 2023 report Infant and Early Childhood Mental Health: The Case for Action, found that 20.1% of children aged one to seven meet the criteria for a mental health condition. One in five. Anxiety disorder accounts for 8.5%. Oppositional defiant disorder for 4.9%. ADHD for 4.3%. Depressive disorder for 1.1%. These are not adolescent diagnoses. These are conditions presenting in children who have barely learned to speak.
Mental health conditions in the under-fives rarely look like mental health conditions. They look like persistent tantrums, social withdrawal, eating difficulties, sleeping problems, or an inability to form relationships. Without appropriate support, these difficulties become entrenched. A behavioural signal becomes, over time, a diagnosable condition.
The Royal College of Psychiatrists is clear on this point. Difficulties in the parent-infant relationship disrupt the baby's developing emotional regulation systems. This increases the risk of multiple mental health conditions. Attachment - the infant's instinct to seek comfort and protection from a recognised caregiver - is not a soft, peripheral concern. It is a biological and developmental necessity.
This matters enormously for early childhood education and care. Children under five spend significant portions of their day in ECEC settings. The quality of those settings is therefore not merely an educational question. It is a mental health question.
The evidence on what undermines quality is clear. Low staff-to-child ratios reduce the quality and frequency of meaningful interactions between staff and children. As the number of children per staff member rises, communication shifts - less positive verbal interaction, more routine and restrictive exchanges. Children become less cooperative. They perform worse in cognitive and linguistic assessments. High staff turnover compounds the problem further. It disrupts the consistency of relationships that young children depend upon for healthy socio-emotional development.
I want to be explicit. When we tolerate inadequate staffing ratios - and the Director of the DQSE told the Family Affairs Committee that 70% of quality inspections in 2023 found centres in breach - we are not accepting a workforce management problem. We are causing harm to children's mental health.
The Royal College of Psychiatrists' report draws on multiple studies to establish this clearly. Children of mothers with no qualifications are almost four times as likely to have socio-emotional or behavioural problems as those whose mothers hold degree-level qualifications. Under-fives in the lowest-income households are twice as likely to have a mental health condition as peers in higher-income households. Where a parent receives disability and low-income benefits, the rate rises to 10.4%, against 2.8% for those not receiving benefits.A systematic review found that socio-economically disadvantaged children aged four to eighteen were two to three times more likely to develop mental health conditions than their more affluent peers.
Getting a parent into work does not automatically lift a family out of the conditions that generate developmental risk. I do not think Malta has adequately confronted that.
The same Royal College report documents that more than half of all children aged two to seventeen globally experienced emotional, physical, or sexual violence in the previous year. In Europe, 23.5% of individuals have experienced at least one adverse childhood experience. Nearly 19% have experienced two or more.These experiences reshape the developing brain, alter emotional regulation, and increase vulnerability to mental health conditions across the life course. A well-staffed, relationally stable ECEC setting can act as a partial buffer. An understaffed, high-turnover setting cannot. It becomes another variable that compounds risk.
The implications are not complicated. They require political will.
Staffing ratios must be treated as a mental health intervention. Socio-economic deprivation must be addressed as a public mental health priority - child poverty is an active risk factor, not a background condition. ECEC practitioners need training, stable conditions, and professional support to identify early signs of difficulty. The parent-infant relationship must be supported, not assumed - parenting programmes and accessible family mental health services are foundational, not optional.
The evidence is international. The challenge is local. I do not think Malta has adequately confronted that. The structural conditions that drive poor mental health outcomes in early childhood - inadequate ECEC resourcing, child poverty, and adverse experiences - are present here. The question is no longer whether the evidence is sufficient. It is whether we have the will to act on it.
This is the penultimate blog in this series. The final blog - Growing Up Struggling: Mental Health Through Childhood and Adolescence - will trace the trajectory forward: what happens to children who do not receive adequate early support as they move through school and into adolescence, and what that picture looks like for Malta specifically.
David Spiteri Gingell is a Governance, Institutional, and Digital Transformation Consultant