This module covers assessment and management of developmental disorders, behavioural disorders, and emotional disorders in children and adolescents.
DEVELOPMENTAL DISORDER is an umbrella term covering disorders such as intellectual disability as well as autism spectrum disorders. These disorders usually have a childhood onset, impairment or delay in functions related to central nervous system maturation, and a steady course rather than the remissions and relapses that tend to characterize many other mental disorders.
BEHAVIOURAL DISORDERS is an umbrella term that includes specific disorders such as attention deficit hyperactivity disorder (ADHD) and conduct disorders. Behavioural symptoms of varying levels of severity are very common in the general population. Only children and adolescents with a moderate to severe degree of psychological, social, educational or occupational impairment in multiple settings should be diagnosed as having behavioural disorders.
EMOTIONAL DISORDERS are among the leading mental health-related causes of the global burden of disease in young people. Emotional disorders are characterized by increased levels of anxiety, depression, fear, and somatic symptoms.
Children and adolescents often present with symptoms of more than one condition and sometimes the symptoms overlap. The quality of home and social educational environments influence children's and adolescents' wellbeing and functioning. Exploring and addressing psychosocial stressors along with opportunities to activate supports are critical elements of the assessment and management plan.
CMH 1. Assessment
TABLE 1COMMON PRESENTATIONS OF CHILD & ADOLESCENT MENTAL & BEHAVIOURAL DISORDERS BY AGE GROUP
May be reported by carer, self-reported or observed during the assessment process.
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| DEVELOPMENTAL DISORDERS | BEHAVIORAL DISORDERS | EMOTIONAL DISORDERS |
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| Infants and Young Children (age <5) |
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Poor feeding, failure to thrive, poor motor tone, delay in meeting expected developmental milestones for appropriate age (eg. smiling, sitting, interacting with others, sharing attention, walking, talking and toilet training
| Ages 4-18
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Excess over-activity: excessive running around, extreme difficulties remaining seated, excessive talking or moving restlessly - –
Excessive inattention, absent-mindedness, repeatedly stopping tasks before completion and switching to other activities - –
Excessive impulsivity: frequently doing things without forethought - –
Repeated and continued behaviour that disturbs others (e.g. unusually frequent and severe tantrums, cruel behaviour, persistent and severe disobedience, stealing) - –
Sudden changes in behaviour or peer relations, including withdrawal and anger
|
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Excessive crying, clinging to a carer, freezing (holding the body very still and being silent) and/or tantrums - –
Extreme shyness or changes in functioning (e.g. new wetting or soiling behaviour or thumb sucking) - –
Diminished initiation of play and social interaction - –
Sleep and eating difficulties
|
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| Middle Childhood (age 6-12) |
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Delay in reading and writing - –
Delay in self-care such as dressing, bathing, brushing teeth
|
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Recurrent, unexplained physical symptoms (e.g. stomach ache, headache, nausea) - –
Reluctance or refusal to go to school - –
Extreme shyness or changes in functioning (e.g. new wetting or soiling behaviour or thumb sucking)
|
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| Adolescents (age 13-18) |
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Poor school performance - –
Difficulty understanding instructions - –
Difficulty in social interaction and adjusting to changes
|
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Problems with mood, anxiety or worry (e.g. irritable, easily annoyed, frustrated or depressed mood, extreme or rapid and unexpected changes in mood, emotional outbursts), excessive distress - –
Changes in functioning (e.g. difficulty concentrating, poor school performance, often wanting to be alone or stay home)
|
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| All Ages |
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Difficulty carrying out daily activities considered normal for the person's age; difficulty understanding instructions; difficulty in social interactions and adjusting to changes; difficulties or oddities in communication; restrictive/repetitive patterns of behaviours, interests and activities
|
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Excessive fear, anxiety or avoidance of specific situations or objects (e.g. separation from caregivers, social situations, certain animals or insects, heights, closed spaces, sight of blood or injury) - –
Changes in in sleeping and eating habits - –
Diminished interest or participation in activities - –
Oppositional or attention-seeking behaviour
|
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CMH 2. Management
PSYCHOSOCIAL INTERVENTIONS
2.1. Guidance to promote child/adolescent well-being and functioning
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Can be provided to all children, adolescents and carers even if no disorder is suspected.
ENCOURAGE THE CARER TO
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Spend time with their child in enjoyable activities. Play and communicate with their child/adolescent. http://www.who.int/maternal_child_adolescent/documents/care_child_development/en/
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Listen to the child/adolescent and show understanding and respect.
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Protect them from any form of maltreatment, including bullying and exposure to violence in the home, at school, and in the community.
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Anticipate major life changes (such as puberty, starting school, or birth of a sibling) and provide support.
ENCOURAGE AND HELP THE CHILD / ADOLESCENT TO
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Get enough sleep. Promote regular bed routines and remove TV or other electronic devices with screens from the sleeping area/bedroom.
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Eat regularly. All children/adolescents need three meals (breakfast, mid-day, and evening) and some snacks each day.
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Be physically active. If they are able, children and adolescents aged 5-17 should do 60 minutes or more of physical activity each day through daily activities, play, or sports. See www.who.int/dietphysicalactivity/publications/recommendations5_17years
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Participate in school, community, and other social activities as much as possible.
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Spend time with trusted friends and family.
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Avoid the use of drugs, alcohol, and nicotine.
2.2. Psychoeducation to person and carers and parenting advice
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Explain the delay or difficulty to the carer and the child/adolescent as appropriate and help them identify strengths and resources.
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Praise the carer and the child/adolescents for their efforts.
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Explain to the carer that parenting a child/adolescent with an emotional, behavioural or developmental delay or disorder can be rewarding but also very challenging.
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Explain that persons with mental disorders should not be blamed for having the disorder. Encourage carers to be kind and supportive and show love and affection.
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Promote and protect human rights of the person and the family and be vigilant about maintaining human rights and dignity.
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Help carers to have realistic expectations and encourage them to contact other carers of children/adolescents with similar conditions for mutual support.
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Guidance for improving behaviour can be provided to all carers who are having difficulty with their child/adolescent's behaviour even if a behavioural disorder is not suspected.
2.3. Guidance for improving behaviour
ENCOURAGE THE CARER TO
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Give loving attention, including playing with the child every day. Provide opportunities for the adolescents to talk to you.
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Be consistent about what your child/adolescent is allowed and not allowed to do. Give clear, simple, and short nstructions on what the child should and should not do.
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Give the child/adolescent simple daily household tasks to do that match their ability level and praise them immediately after they do the task.
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Praise or reward the child/adolescent when you observe good behaviour and give no reward when behaviour is problematic.
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Find ways to avoid severe confrontations or foreseeable difficult situations.
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Respond only to the most important problem behaviours and make punishment mild (e.g. witholding rewards and fun activities) and infrequent compared to the amount of praise.
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Put off discussions with the child/adolescent until you are calm. Avoid using criticism, yelling, and name-calling.
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DO NOT use threats or physical punishment, and never physically abuse the child/adolescent. Physical punishment can harm the child-carer relationship; it does not work as well as other methods and can make behaviour problems worse.
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Encourage age-appropriate play (e.g. sports, drawing or other hobbies) for adolescents and offer age-appropriate support in practical ways (e.g. with homework or other life skillls).
2.4. Psychoeducation for developmental delay/disorder
ENCOURAGE THE CARER TO
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Learn what the child's strengths and weaknesses are and how they learn best, what is stressful to the child and what makes him/her happy, and what causes problem behaviours and what prevents them.
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Learn how the child communicates and responds (using words, gestures, non-verbal expression, and behaviours).
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Help the child develop by engaging with her/him in everyday activities and play.
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Children learn best during activities that are fun and positive.
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Involve them in everyday life, starting with simple tasks, one at a time. Break complex activities down into simple steps so that the child can learn and be rewarded one step at a time.
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Make predictable daily routines by scheduling regular times for eating, playing, learning, and sleeping.
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Keep their environment stimulating: avoid leaving the child alone for hours without someone to talk to and limit time spent watching TV and playing electronic games.
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Keep them in the school setting for as long as possible, attending mainstream schools even if only part-time.
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Use balanced discipline. When the child/adolescent does something good, offer a reward. Distract the child/adolescent from things they should not do.
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DO NOT use threats or physical punishments when the behaviour is problematic.
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Persons with developmental disorders may often have associated behavioural problems that are difficult for the carer to manage. See guidance for improving behaviours. (2.3)
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Promote and protect the human rights of the person and family and be vigilant about maintaining human rights and dignity.
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Educate carers to avoid institutionalization.
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Promote access to health information and services.
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Promote access to schooling and other forms of education.
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Promote access to occupations.
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Promote participation in family and community life.
2.5. Psychoeducation for emotional problems/disorders including depression in adolescents
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Address any stressful situation in the family environment such as parental discord or a parent's mental disorder. With the help of teachers explore possible adverse circumstances in the school environment.
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Provide opportunities for quality time with the carer and the family.
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Encourage and help the child/adolescent to continue (or restart) pleasurable and social activities.
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Encourage the child/adolescent to practice regular physical activity, gradually increasing the duration of sessions.
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Consider training the child/adolescent and carer in breathing exercises, progressive muscle relaxation and other cultural equivalents.
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Make predictable routines in the morning and at bedtime. Promote regular sleep habits. Schedule the day with regular times for eating, playing, learning, and sleeping.
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For excessive and unrealistic fears:
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Praise the child/adolescent or give small rewards when they try new things or act bravely.
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Help the child practice facing the difficult situation one small step at a time (e.g. if the child is afraid of separating from the carer, help the child gradually increase the amount of time he/she plays alone while the carer is nearby).
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Acknowledge the child's feelings and worries and encourage them to confront their fears.
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Help the child/adolescent create a plan to help them cope in case a feared situation occurs.
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Explain that emotional disorders are common and can happen to anybody. The occurrence of emotional disorders does not mean that the person is weak or lazy.
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Emotional disorders can cause unjustified thoughts of hopelessness and worthlessness. Explain that these views are likely to improve once the emotional disorders improve.
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Make the person aware that if they notice thoughts of self-harm or suicide, they should tell a trusted person and come back for help immediately.
2.6. Carer support
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Assess the psychosocial impact of the child/adolescent's disorders on the carers, and offer support for their personal, social, and mental health needs.
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Promote necessary support and resources for their family life, employment, social activities, and health.
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Arrange for respite care (trustworthy carers taking over care on a short term basis) to give primary carers a break, especially if the child has a developmental disorder.
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Support family to handle social and familial problems and help to problem solve.
2.7. Liaise with teachers and other school staff
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After getting consent from the child/adolescent and carer, contact the child/adolescent's teacher and provide advice/make a plan on how to support the child with learning and participation in school activities.
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Explain that the child/adolescent's mental disorder is affecting their learning/behaviour/social functioning and that there are things the teacher can do to help.
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Ask about any stressful situations that may have an adverse impact on the child's emotional well-being and learning. If the child is being bullied, advise the teacher on appropriate action to stop it.
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Explore strategies to help engage the child in school activities and facilitate learning, inclusion, and participation.
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Simple tips:
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Provide opportunities for the child/adolescent to use their skills and strengths.
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Ask the student to sit at the front of the class.
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Give the student extra time to understand and complete assignments.
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Divide long assignments into smaller pieces and assign one piece at a time.
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Provide extra praise for effort and rewards for achievements.
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DO NOT use threats or physical punishments or excessive criticism.
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For students with significant difficulties in the classroom, recruit a volunteer to come to class to provide one-on-one attention or pair the student with a peer who can provide support or help with learning.
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If the child/adolescent has been out of school, help them return as soon as possible by creating a gradually increasing reintegration schedule. During the reintegration period, the student should be excused from quizzes and exams.
2.8. Brief psychological treatments
This guide does not provide specific protocols to implement brief psychological interventions, such as parent skills training, interpersonal therapy and behavioural therapy. WHO has developed Parent Skills Training package for caregivers of children with developmental delay/disorders and is available on request.
