The assessment and management of the following conditions:

Attention-deficit/hyperactivity disorder (ADHD), according to the American Psychiatric Association (2000) is one of the most common and well-researched childhood psychiatric conditions. It is characterized by features of inattention and inability to sustain focus, hyperactivity and impulsivity. The impairment that it causes depends on the age and developmental stage of the child. Oftentimes scholastic difficulties, emotional and behavioural problems are a concern in the child with ADHD.

ADHD commonly co-occurs with problems like anxiety, learning difficulties, and behavior disorders. It can be safely managed by medication; as well as environmental interventions and family support. – Attention Deficit and Hyperactivity Support Group of Southern Africa

Anxiety disorders in children and adolescents are the most commonly occurring psychiatric difficulties in youth and include separation anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, social anxiety disorder and selective mutism.
Anxiety in childhood has an adverse effect on the child’s self-esteem, social relationships and academic performance. Anxiety may sometimes result in a child refusing to go to school. What is worrying about anxiety in children is, not only that it constricts the child’s socio-emotional development, but the fact that it puts the young person at risk for anxiety disorders in adulthood. It is important to make a distinction between what are normal and developmentally appropriate worries and what has become ‘pathological’ anxiety. It is quite typical for anxiety in young children to present with lots of unexplained physical symptoms as well as puzzling “bad behaviour”. – South African Depression and Anxiety Group

Unfortunately with South Africa being one of the most violent countries in the world, children are exposed on a daily basis to unacceptable and traumatic experiences – domestic violence, rape, crime in its various guises, motor vehicle accidents, and violent protest action. They are extremely vulnerable to developing emotionally disabling trauma responses, particularly in instances when the adults in their lives are unable to support them in making sense of the threat and horror of what they have experienced. Children and adolescents develop acute and post-traumatic stress disorder (PTSD) in which they become agitated and relive and re-experience the trauma that they were exposed to. These are manageable psychiatric conditions.

The more worrying and pervasive problem is exposure to chronic trauma. This usually occurs in the guise of child maltreatment or abuse and is more often than not perpetrated by the child’s caregivers. Trauma of this nature has a profound and disturbing influence on the child’s development – emotionally, behaviourally and cognitively. This is called complex trauma and puts the child at risk for multiple and severe psychiatric problems.

In order for children to thrive they do not only require nutrition, physical well- being and education; they need a nurturing environments in which to grow. Unfortunately these basic requirements are sometimes not met. According to the World Health Organization, “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”.

Maltreatment in its various guises is responsible for significant emotional, behavioural and cognitive difficulties in the children and adolescents who suffer these indignities. Moreover, these young people are at substantial risk for the development of psychiatric problems that include depression, anxiety and trauma responses, as well as dissociative disorders, substance use disorders and severe behaviour and personality disorders. The prospect of maladaptive responses in affect (mood) regulation, relationships and problem solving skills is high in these children, resulting in huge challenges in a number of areas in their lives.

Once considered rare in childhood and adolescence, it is now acknowledged that depression does occur early in life. In childhood it is often associated with mood reactivity and irritability, as well as co-occurring disruptive behaviour. Adolescents on the other hand may present with features similar to adults; they are often anxious, are high risk for substance misuse and suicidal behaviour.

There are a number of factors that serve as risks for the development of depression: these include being female (after adolescence), family stressors, peer rejection, trouble with romantic relationships, abuse or maltreatment, chronic medical conditions and family history.

Suicidal thoughts and behaviours remain an extremely worrying phenomenon. Unfortunately a number of young people contemplate suicide and several engage in repeated suicide attempts. Aside for mental health problems, there are several factors correlated with suicidal behaviour – those foremost on the list include bullying and substance misuse.

There is a distinction between suicidal behaviour and so-called deliberate self-harm/ non-suicidal self-injury. Self-injury is often associated with the child or adolescents’ attempts to manage unbearable emotional states.

Young people on the autistic spectrum present with a complex set of difficulties. The autistic spectrum is considered to be a group of neuropsychiatric disorders with specific challenges in, and variations from, developmentally expected social behaviour and communication. It is often accompanied by a repetitive and restricted patterns of behaviour and interests. Many children and adolescents on the autistic spectrum struggle with sensory integration problems. There are often times associated learning and/or cognitive problems.

The world is often experienced as bewildering and demanding by children and adolescents on the autistic spectrum, and they are at considerable risk for developing psychiatric problems including anxiety and depression. They have a number of associated problems that include attention-deficit hyperactivity disorder (ADHD), learning and cognitive problems, sleep disorders and seizures – the management of which requires input of a multidisciplinary team.

There is much debate and controversy as to how bipolar disorder presents in children and adolescents. On one hand children may manifest distinctly abnormal, persistently elevated, expansive or irritable mood states; on the other there is a belief that chronic undulant irritability with a low threshold for experiencing anger in response to negative emotional events is indicative of paediatric bipolar disorder. Childhood-onset bipolar can be profoundly disruptive in the life of the child and family concerned and usually requires treatment with mood stabilizing medication, that needs to be carefully monitored and managed.
Living with chronic illness is a reality for many children and adolescents. They must endure pain, fatigue and physical incapacity, multiple medical procedures and tolerate the impact of taking medication on a daily basis. As a result psychiatric difficulties are all too common in this population of children – anxiety disorders, depression and even psychosis may arise.
Children and adolescents with severe behaviour disorders present the largest single group of patients in child and adolescent mental health settings. The disruptive behaviours which include aggression, defiance, chronic irritability, unacceptable flouting of societal norms, deviance, deception and interpersonal relationship difficulties, often come to clinical attention as a result of the impact of the young person’s behaviour on others in their lives.

In many regards disruptive behaviour disorders (oppositional defiant disorder and conduct disorder) do not fit an “illness model” and require structural and environmental interventions as opposed to psychiatric treatment. Nonetheless there are high rates of psychiatric and emotional difficulties, risk for substance misuse and suicidal behaviour associated with behavioural problems – these may be mitigated by psychiatric intervention.

Psychotic disorders are uncommon in children. Childhood-onset schizophrenia in particular is rare; and psychotic symptoms in children and adolescents are usually associated with mood disorders, medical conditions, behaviour disorders and autism spectrum disorders.
Problems with wetting (enuresis) and soiling (encopresis), occurring outside of what is considered developmentally appropriate, are diagnoses in and of their own right. These behaviours are, however commonly manifestations of other emotional and behavioural difficulties which require attention, e.g. severe anxiety, oppositional defiant disorder.
Learning and education is the central focus of children and their parents’ lives, and increasingly education is seen as a priority to achieve psychosocial success. Language and learning disorders are extremely common and often go unrecognized, resulting in children being labeled as “lazy”, “unmotivated” and “not living up to potential”. The resultant impact on a child’s self-esteem and confidence can be particularly destructive. This in turn may manifest in emotional and behavioural difficulties, in addition to the scholastic challenges.

Learning disorders arise “..when the individual’s achievement on individually administered, standardized tests in reading, mathematics, or written expression is substantially below that expected for age, schooling and level of intelligence.” These difficulties often co-occur with well-defined psychiatric conditions such as attention-deficit hyperactivity disorder (ADHD), and may also give rise to psychiatric difficulties like anxiety disorders and depression. Formal psycho-educational assessment is very useful in objectively evaluating and documenting the nature of these disorders.

Intellectual disability involves impairments of general mental abilities that impact adaptive functioning in three domains, or areas. These domains determine how well an individual copes with everyday tasks:

  • The conceptual domain includes skills in language, reading, writing, math, reasoning, knowledge, and memory.
  • The social domain refers to empathy, social judgment, interpersonal communication skills, the ability to make and retain friendships, and similar capacities.
  • The practical domain centers on self-management in areas such as personal care, job responsibilities, money management, recreation, and organizing school and work tasks.

Children and adolescents with intellectual disability present with a range of cognitive capacities and accompanying developmental delays. The difficulties experienced by the child suffering with milder disabilities may escape detection initially and only become evident in middle childhood or early adolescence with the advent of substantial challenges at school. This is often accompanied by emotional and/or behavioral acting out.

Those on the moderate to severe spectrum may be quite notably impaired in their adaptive functioning, and are not immune from suffering from emotional and psychiatric difficulties. Their capacity to communicate and convey their distress may handicapped, and this requires careful evaluation

Many children and adolescents struggle as a result of a strong identification with, and preference for, the gender role and characteristics of the other sex. It is acknowledged that many young people experience extreme discomfort with their gender variance, which is known as gender dysphoria. These children face enormous challenges with ostracism and peer relationship difficulties. Emotional and behavioural problems are commonplace in this cohort of young people.
The emotional health of an expectant mother is as important as the physical well-being of a pregnancy. Stress, depression and anxiety can potentially have an impact on the developing child in utero. Even more so, the mental health of the mother/ caregiver has a profound impact on the infant child and the mother’s ability to bond to her baby. The caliber of this bonding/attachment will provide a template for the child’s interpersonal relationships in future. It thus becomes pivotal that the mother is supported in the postnatal period and any signs of depression and/anxiety be addressed with urgency.
Many adolescents experiment with substances of abuse, fewer develop substance related problems and a sub-set of these children go on to develop chronic substance use disorders, i.e dependence or addictions. The substances themselves may cause substantial emotional and behavioural changes, but are more worryingly associated with the development of severe psychiatric difficulties, like psychosis (in particular schizophrenia), mania and depression.