Children and Adolescents

• Create a safe comfortable place when talking with the child, it does not have to be a clinical setting – a box of toys or crayons can help with younger children. Adolescents may be more comfortable in an informal setting.
• It is always necessary to consider the family/carer in the assessment and intervention
• You should speak to the young person alone, especially if you have concerns about abuse – see box below. Tell the guardian that it is routine to have time alone with the child in order to assess properly. Explain to the child that you will not share any information unless they give permission or there is an emergency situation.
• Ask the young person directly about any abuse, if developmentally appropriate and safe (e.g. not in the presence of carer who may have been abusive).
• You may also need to talk to the guardian alone, explain this to the young person.
• DO NOT consider starting medication – refer to a specialist if you think medication is necessary

At every visit:

• For all children, but especially those under 5 years, monitor child development.
• Assess for the presence of any new problem or symptom related to mood, behaviour or development/learning. For adolescents, assess for the presence of worsening mood (irritable, easily annoyed or frustrated, down or sad) or suicidal thoughts or abnormal thought processes or experiences such as hallucinations or delusions. Refer to risk assessment and suicide sections for more.
• Explore and address psychosocial stressors in the home, school or work environment, including exposure to violence or other forms of maltreatment.
• Assess opportunities for the young person to participate in family and social life.
• Assess carers’ needs and support available to the family.
• Monitor attendance at school or workplace.
• Review management plan and monitor adherence to psychosocial interventions.
• If already on medication, review adherence, side-effects, and dosing.
• DO NOT consider starting medication – refer to a specialist if you think medication is necessary

• All children will show challenging behaviours at some time or another, especially when they are young. This is normal – see box.
• When the disruptive behaviour is present for many months and is consistently associated with breaking family or school rules by lying, stealing, bullying, fighting or not attending school or workplace, then this is a mental health problem.
• Encourage families to regularly spend time on activities which both the child and parent enjoy.

The most common underlying cause of this problem is domestic abuse, which may or may not be directed at the child (they may witness it instead) and be a cause of inconsistent parental discipline. Hyperactivity (ADHD), intellectual disability and dyslexia are among other causes (see Where There is no Psychiatrist chapter 11).

Practising simple ways of encouraging positive behaviour and encouraging parent–child contracts on acceptable behaviours are the key methods of dealing with this problem.

Medication has no role except to treat underlying causes.

Toddlers and young children (18 months – 5 years)

• Refusing to do what they are told, breaking rules, arguing, whining, exaggerating, saying things that aren’t true, denying they did anything wrong, being physically aggressive and blaming others for their misbehaviour.
• Brief tantrums (emotional outbursts with crying, screaming, hitting, etc.), usually lasting less than 5 minutes and not longer than 25 minutes, typically occur less than 3 times per week.

Middle Childhood (6 – 12 years)

• Avoidance of or delay in following instructions, complaining or arguing with adults or other children, occasionally losing their temper.

Adolescents (age 13-18 years)

• Testing rules and limits, saying that rules and limits are unfair or unnecessary, occasionally being rude, dismissive, argumentative or defiant with adults.

The following interventions have been largely adapted from the mhGAP Intervention Guide which is freely available online – see download information in introduction to this book.

Promoting well-being

Advice for carer

• Spend time with young person doing fun activities
• Listen to the young person and show them affection and respect
• Protect young person from any maltreatment
• Anticipate major life changes (puberty, starting school, birth of sibling) and provide support.

Advice for young person

• Lifestyle choices are crucial: get enough sleep, eat regularly, be physically active, spend time with trusted friends and family, avoid drugs and alcohol, participate in school and social activities.

Parenting Advice

Explain:

• the cause of the developmental delay or mental health difficulty to the carer and the young person in an understandable way
• to the carer that parenting someone with an emotional, behavioural or developmental delay or disorder can be rewarding but also very challenging.
• that people with mental disorders should not be blamed for having the disorder.

Help:

• carers and the young person to identify strengths and resources
• carers to be kind and supportive and show love and affection
• promote and protect human rights of the person and the family and be vigilant about maintaining human rights and dignity
• carers to have realistic expectations and encourage them to contact other carers of children/adolescents with similar conditions for mutual support – see MeHUCA contact details.

Praise the carer and the young person for their efforts.

For further guidance on psychosocial interventions for young people with developmental, behavioural and emotional problems, see the mhGAP Intervention Guide. 

Definition: “Child abuse or maltreatment constitutes all forms of physical and/or emotional ill treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power" (WHO, 2016).

• Child abuse is much more common than is actually reported as most children are too scared or embarrassed, or feel they are to blame.
• The most common type of abuser is someone whom the child knows, male or female – often a parent, other relative, domestic help or family friend.
• Boys can be abused as well as girls.
• Abuse can be emotional, physical or sexual. All three types of abuse can damage the physical and mental health of children.
• Look for signs of abuse like unexplained injuries, age inappropriate sexual talk/play, sexually transmitted infections, being excessively dirty or wearing unsuitable clothing, withdrawn or fearful of parents, and carer using inappropriate threats (e.g. to abandon their child).
• It is important for you to inform the parents and relevant authorities immediately if you suspect abuse. It is essential to follow up on the action taken, especially when the abuser is in a position of authority, for instance, a teacher.
• Never doubt a child’s claims that they are being abused. Take it seriously since it will not stop until someone intervenes and addresses the problem.