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Non-Communicable Diseases, Emergency Care and Mental Health Module: 17. When Children Have Problems
Study Session 17 When Children Have Problems
Introduction
A happy and healthy childhood is very important for the future of children (Figure 17.1). Children who have problems in early life often continue to have problems in adulthood. By preventing or treating childhood problems, we can help to establish a mentally healthy population. Children need to be given the opportunity to grow intellectually, emotionally, and behaviourally as well as physically. Most childhood problems arise when development in these areas is slow or abnormal. In this session you will learn about the most common and most important problems in the intellectual, emotional and behavioural development of a child. You will also learn what to do when you suspect a child may have these problems.
Learning Outcomes for Study Session 17
When you have studied this session, you should be able to:
17.1 Define and use correctly all of the key words printed in bold. (SAQs 17.1 and 17.2)
17.2 Identify important and common problems that occur in childhood. (SAQ 17.2)
17.3 Explain how you support families with children who have intellectual disabilities. (SAQ 17.1)
17.4 Describe what enuresis is and what you can do to support the family and the affected child. (SAQ 17.2)
17.5 Describe the common forms of child abuse and its impacts. (SAQ 17.1)
17.6 Identify the main reasons for referring a child with problematic behaviour. (SAQ 17.3)
17.1 When children develop normally
There are large variations in the way children develop. But there are some characteristics in physical, language and emotional development that all children have in common. Table 17.1 and Figure 17.2 present some important developmental milestones (significant events in development that are achieved by most children around a particular age) in early childhood. The exact age by which these milestones are achieved varies from child to child, but when there is a serious deviation from these typical developmental milestones, there is reason for concern. In the following sections we will discuss a few important conditions in which the typical development is delayed or abnormal.
| Age | Physical development | Language development | Emotional development |
|---|---|---|---|
| 0–1 years | 4 months: sits with support 8 months: stands 9 months: crawls | 4 months: laughs aloud 8 months: repetitive responding 10 months ma-ma, ba-ba | Issues of trust are key 9 months: stranger anxiety; exploratory and solitary play 10 months: plays peek-a-boo |
| 1–2 years | 13 months: starts to walk 2 years: walks alone | 2 word sentences | Imitates No is favourite word |
| 2–3 years | High activity level Eats, drinks by self | Parents understand more of what the child says | Selfish Imitates mannerisms and activities May be aggressive |
| 3–4 years | Toilet trained. But bladder control may be delayed up to the age of 5 years | Complete sentences Understands much more | Gender-specific play Takes turns Knows full names and gender |
| 4–5 years | Hops on one foot Avoids simple hazards | Can tell stories | Nightmares and fear of monsters Imaginary friends |
| 5–6 years | Complete toilet control | Asks the meaning of words | Important to conform with peers |
17.2 A child who develops slowly
In the previous section you learned about the typical developmental milestones. When there is significant delay in achieving these milestones, you should think about the possibility of intellectual disability (ID), formerly referred to as mental retardation. ID is characterised by a delay in the intellectual development of a child compared with children of the same age. ID impairs the ability of a child to carry out expected day-to-day activities adequately. Children with ID may, for instance, have difficulty in the following areas:
- Simple skills such as getting dressed, feeding oneself, and washing
- Skills to communicate or engage with others (being able to understand what others say and to be able to answer back)
- Certain social skills to get along with friends and family members.
17.2.1 What causes intellectual disability?
The primary cause of ID appears to be problems with the development of the brain. In most children with ID we do not know precisely why the children have ID. But some of the factors that we know about include:
- Problems before the child is born: poor nutrition or excessive alcohol consumption by the mother during pregnancy, exposure to certain types of infections prenatally.
- Problems during childbirth: prolonged labour.
- Problems in the first year of life: infections of the brain; accidents or severe malnutrition.
- Some genetic conditions, for example Down syndrome.
Down syndrome is the commonest identifiable cause of ID in Europe. A child with Down syndrome is usually of short stature and has physical characteristics (including an unusually round face, a protruding or oversized tongue and unusually shaped eyes) that make them look different from other children. The mother’s age is the commonest risk factor in relation to Down syndrome: at age 28, the risk is about 1 in 800 live births, at the age of 38, the risk increases to about 1 in 200; and by the age of 48, this rises dramatically to about 1 in 10 live births. Given this, one of the things you can do in your community is to encourage women to try and avoid pregnancy after the age of 40.
Other risk factors that may affect the intellectual development of a child include problems in the way the child is being looked after, such as poor stimulation, child abuse and emotional neglect.
17.2.2 What can you do when you suspect ID?
There is no cure for ID. But there are things that can be done to make sure that there are no treatable problems affecting intellectual development that are being missed.
Tessema, a 3-year-old toddler, appears withdrawn and unhappy. His parents tell you that he has grown well physically but has problems talking. They also tell you that when he was 3 months old, he had a fever and discharge coming from his ear. They are concerned that, because he has not been able to talk, he may have ID. How would you proceed?
ID is not just about a child having problems with language development. ID is more pervasive and affects a child’s physical and emotional development as well. Language is an important indicator of intellectual development but it is not the only indicator. The first thing to consider in the case of Tessema is whether a problem with his hearing has caused a delay in his talking. At 3 months he had what appears to be an ear infection, which may have caused the problems with language development. However, before concluding that Tessema’s problem is just to do with his hearing, confirm that there are no problems with his physical and emotional development (Table 17.1 and Figure 17.2). If you suspect hearing problems, or if you are unable to exclude this possibility, refer Tessema to the next healthcare facility for further assessment and advice.
As noted above, under-stimulation can also make a child appear developmentally slow. As Tessema is withdrawn, this is a possibility, although it is relatively uncommon. You should check how Tessema’s family interacts with him. If you find that there is very little interaction between him and the family, you can gently suggest ways in which the family might encourage stimulation. For example, you can ask the family to try and talk to Tessema regularly, to take him out of the house on a daily basis, and to allow him to play with other children.
Although ID cannot be cured, there are several other things that can be done. You can play a key role in educating the parents, other relevant family members and the child’s teachers about the child’s difficulties, and give them information on how to best support the child.
17.2.3 Educating parents
Emotional reaction of parents
The birth of a child with ID can be a shock for the parents. Parents who have a child with ID are likely to experience a range of strong emotions. Some parents feel guilty when a child has ID. You should help them understand that it is not their fault and can happen to anyone. Some parents also feel ashamed to have a child with ID. Explain to them that ID is more common than they may think. They may not know other children with similar problems simply because their parents also don’t want other people to know about it.
Living with a child with ID can, at times, be stressful. For example, when the child becomes ill but has difficulty in communicating their distress or describing their problems; or when the child becomes an adolescent and their behaviour changes in response to the challenges of this difficult developmental period. Caring can itself be a cause of stress and mental health problems and parents will require support, particularly during these times of stress. Despite these difficulties and challenges, most parents of a child with ID have a good quality of life. Many parents discover that their children – as well as having special needs – have special qualities that add to the joy of family life.
What parents should expect
It will take parents a long time, in some cases years, to accept that their child has significant limitations. It is important to be sensitive and tactful when you discuss these difficulties or talk about the child’s future. You should be open and honest with parents in providing advice and information, but you should do this in a way that is sensitive to their fears and concerns.
In general, what can be expected will depend on the cause of the ID and its severity. When ID is moderate to severe, the child will require a lot of support. Some will be able to take care of themselves, in terms of eating for themselves, dressing and the like. Others may require support in these areas. Children with mild ID (which is the majority of cases) will be independent in the above functions. Many will be able to attend school but their teachers need to understand and be able to respond to the specific needs of these children. Children with ID are also likely to experience difficulty in making friends as they grow up and, as adults, in finding and sustaining paid employment.
You have probably seen many children with ID helping their parents in different activities, for example on the farm. Can you provide other examples of activities where those with ID may be able to help their parents/carers?
Children with ID can do many simple errands like washing and cleaning, looking after cattle, fetching water, picking up shopping, etc. Some may be able to hold paid employment and help their families financially. The list given here is only an example; there are probably many more chores you can think of.
Specific things parents can do to support their child
Just like typically developing children, children with ID are sensitive to the emotions of their carers. It is thus important for them to experience love from their carers (Figure 17.3). Some other concrete things that parents could do to develop their child’s skills are listed in Box 17.1.
Box 17.1 Tips and suggestions for parents
- Parents should not overprotect the child, but should let the child do whatever they can do on their own (Figure 17.4). This will make the child more confident and self-reliant.
- Parents should stimulate the child even if they feel it is pointless. For example, they could talk to the child, beginning by using simple language then raising the level as the child’s language skills improve.
- Parents can provide training in simple social skills such as greeting someone and saying goodbye
- When parents want something from the child, they should explain clearly what they expect from the child and how something is to be done.
- It does not help to be irritated or annoyed with the child. Most of the time, the child does not do it deliberately.
- It is better to praise the child when behaving well and to ignore them when their behaviour is not satisfactory.
17.2.4 Sexual adjustment
The sexual development of those with ID follows a normal course in most cases. It is important that children with ID learn about human sexual relationships and marriage. They are also likely to require education about the physical aspects of sexual intimacy and body function. Parents may find such conversations difficult but it is important that they take place. One reason for this is that, given their intellectual difficulties, those with ID may be open to exploitation and abuse if they have no understanding of sexual matters. Both boys and girls with ID should know about the potential dangers and appropriate protection in this area.
17.2.5 Preventing ID
Once ID has developed it is an irreversible condition. But several steps can be taken to prevent ID. You will be able to support these actions in your community (Box 17.2).
Box 17.2 ID prevention strategies
During pregnancy:
- Antenatal care: good antenatal follow-up
- Avoid medications as much as possible
- Advise mothers to not smoke, consume alcohol or take other drugs during pregnancy
- Prompt treatment if ill
- As much as possible, avoid pregnancy after the age of 40 (because the risk of having a child with problems increases markedly after this)
- Adequate nutrition
- Having a child with ID caused by genetic or congenital problems is a risk factor, increasing the probability that subsequent pregnancies will result in similar problems. Parents should be aware of these risks.
Birth:
- Avoid trauma of the head at birth
- Prevent asphyxia (lack of oxygen) during childbirth.
Early childhood:
- Immunisation against common infections
- Avoid head injury
- Treat infections promptly
- Provide adequate nutrition.
17.3 Enuresis
Enuresis is a term that refers to involuntary urination, either during the daytime or at night, and occurring at an age when complete bladder control is expected. As mentioned in Table 17.1, such control normally occurs around the age of 5 years. If the child had never managed to attain control, this type of enuresis is primary enuresis. If enuresis occurs after a period of complete control lasting 6 months, it is called secondary enuresis.
17.3.1 How common is enuresis and what is its impact?
Enuresis is one of the most common complaints in childhood. At the age of 5 years, about 20% of children have enuresis. At the age of 7, around 5% of children have this problem, while around 1% of 18-year-olds still experience enuresis. Enuresis has an impact on both the child and the family. The child loses self-confidence, may be teased by siblings and friends, and often faces punishment by the parents. The family or parents looking after the child worry about the wellbeing of the child. They may feel frustrated and think that the child can stop wetting if they try harder. But it is very unusual for a child to intentionally wet themselves. Punishing or shaming a child for it will frequently make the situation worse, as the child may feel ashamed and lose confidence in their ability to overcome this problem.
17.3.2 What causes enuresis?
Most enuresis is a developmental or maturational problem and is not related to any physical or mental health problem (Box 17.3). Only 5–10% of children with enuresis have a physical or mental health problem that is causing the enuresis. Enuresis is more common in boys than in girls.
Box 17.3 Some causes of enuresis
- Developmental — 9 out of 10 children with enuresis
- Genetic — if a family member has a history of enuresis, the risk of enuresis is higher
- Infection — infection of the kidney, bladder or urinary passage (urethra). This will result in other symptoms of infection, such as pain during urination, frequent urination and fever
- Physical abnormalities — a small number of children have this problem (for example, a small bladder)
- Constipation
- Stress — such as conflict within the family, birth of a new baby, sickness and anxiety.
17.3.3 Treatment of enuresis
Most parents will manage their child’s enuresis problems in their own way and you may therefore not see many children with enuresis. However, the way the parents manage enuresis may affect the child negatively. Your role is mainly in educating parents about the most effective approaches (see Box 17.4).
Box 17.4 Specific recommendations for managing enuresis
- Waiting — most enuresis is due to a delay in maturation. By waiting a little, the child can often achieve bladder control without intervention.
- Parents should know that punishment does not work. Enuresis is not a condition that a child can control and punishment damages a child’s self-confidence. Some children with enuresis develop behavioural problems, such as disruptive and aggressive behaviour. These behavioural problems can get worse with punishment.
- Parents can try a procedure called dry bed training. In dry bed training parents follow a strict schedule with the child. They make sure that the child urinates at normal times during the day and evening and does not hold urine for long periods of time. They make the child urinate before going to sleep and also wake the child up at night to let them go to the toilet. The goal is to get the child to wake up by themselves in the longer term. Parents should not restrict fluid excessively. Dry bed training however has limited success.
- Parents should praise the child when they have dry nights. But when the child wets the bed, they should ignore it and appear as if they have not noticed.
If you think the child may have underlying physical health problems, you should refer the child to the nearest healthcare facility.
When these methods are unsuccessful the child may be referred for further assessment and treatment, e.g. using medication. If you suspect underlying physical causes, such as infections, diabetes or problems with the bladder, the child should also be referred.
17.4 Child abuse
Child abuse is a very difficult issue to deal with. This is partly because aspects of abuse are common due to a poor understanding of its impact on the child. As a health professional working with the community, it is important that you understand what child abuse is and explain to others the negative impact of this practice on children. You will then be able to teach the community about healthy childrearing.
Child abuse can be defined as the mistreatment of a child that adversely affects the child’s health and development. There are three main types of abuse: physical abuse, emotional abuse and sexual abuse.
Physical abuse occurs when a child is frequently and severely punished (Figure 17.5) so that damage is caused to the child’s emotional or physical health. Sometimes children may be punished or beaten so severely that they sustain serious injuries including broken bones.
Emotional abuse is the commonest form of abuse and can take different forms. It may involve verbal abuse, in which the child is frequently shouted at, mocked and insulted. It may also involve treating one child preferentially while ignoring another. Neglect (in which the child does not receive sufficient love or affection) is another form of emotional abuse that may have very negative consequences for the child’s development.
Sexual abuse occurs when an adult uses a child for sexual pleasure. The adult may touch the child’s sexual organs, make the child touch their sexual organs, or even try to have sexual intercourse with the child.
All these forms of abuse, particularly sexual abuse, may have a lasting emotional impact.
17.4.1 What do you do if you suspect child abuse?
Dealing with child abuse is difficult. It is important to be sensitive and tactful. Your priority must be the health and safety of the child. If you suspect the child is being abused, you may wish to discuss this with the child and – if appropriate (see below) – with other family members. If family members know about the problem, ask what they have done to try to stop it. If they were not aware, ask them about their opinion and what they think should be done. Formulate a plan with the family and then monitor the situation. If the abuse is being done by one or more members of the family, tell them of the potential consequences of what they are doing.
The family should also be aware of the legal protection of the child and that it is a serious criminal offence to harm a child in this manner. Again, monitor the situation. If there is no change and you continue to be concerned, you should do what is locally appropriate. This may include involving other family members, neighbours and local elders in safeguarding the child. It also helps to know what kinds of programmes are available to support children who are victims of abuse. In many parts of the country, there are special police officers with expertise in dealing with victims of abuse. If you have reason to believe that the child’s life is in danger, it will be necessary for you to act immediately in informing the appropriate authorities.
17.5 Other childhood problems
Many children experience behavioural problems growing up, such as feeding difficulties, temper tantrums and sleep problems. These problems usually improve with time, so that no intervention is necessary. However, there are some serious childhood problems where more support may be needed. An example is conduct disorder.
Children with conduct disorder show persistent socially inappropriate behaviour that often involves breaking rules, such as damaging property or stealing. While most children will improve their behaviour when appropriately disciplined by their parents, children with conduct disorder are unresponsive to this. Common symptoms of conduct disorder include temper tantrums, defiance and aggression, irritability, lying and stealing. These children may come to your attention following accidents and injuries. You may be able to support the family of the child, but helping the child with conduct disorder requires more specialist input. If you suspect these problems you should therefore refer the child to the nearest next level health facility.
Children may also have emotional problems such as depression and anxiety (see Study Sessions 12 and 16). These children will appear unhappy and the family may tell you that they are often tearful. They may also have poor appetite, and if the emotional problems are severe the child may start to lose weight. If this happens, you need to refer the child. Emotional problems often develop in response to problems at home or in school. If you identify specific problems you can help the parents to address these. Simply explaining what you see to the parents and allowing the child to talk about their problems will often help. Medication is usually unnecessary unless there is some underlying health problem or the depression is severe.
There are two more conditions that we will mention briefly: autism and attention deficit hyperactivity disorder (ADHD). Children with autism have great difficulty with social interaction and communication, and often show repetitive behaviours (such as rocking or flapping their hands) or a very narrow range of interests and activities. Children with autism often also have ID and delay in their development, especially in their language development, may be one of the first problems noted by the parents.
ADHD is another common developmental condition. Children with ADHD are restless and experience difficulties concentrating on tasks at hand. They often have problems sitting through class, which may get them into trouble with their teachers. They also tend to do things impulsively, without thinking much about the possible consequences of their actions.
If you feel that a child has significant problems with either of these conditions, refer the child to the next level healthcare facility. Children with autism or ADHD are greatly helped by a clear structure in their lives. Their behavioural problems may improve if the children are given a strict daily routine without many unexpected changes or distractions, and by receiving clear instructions from their parents and teachers on what is expected of them.
Summary of Study Session 17
In Study Session 17, you have learned that:
- A healthy childhood is the foundation for a healthy adulthood and a healthy population.
- Childhood is a period of physical, intellectual and emotional development. Typical developmental progress in these areas is mapped by developmental milestones that can help you assess the child’s development in relation to others of a similar age.
- Children with intellectual disability have a delay in intellectual development. This impairment is usually first manifested through delays in motor development (for example when the child starts walking), and poor progress with speech and functioning.
- Having a child with ID requires substantial adjustment on the part of the parents. Despite this, many parents retain a good quality of life and discover special qualities in their children that are emotionally rewarding.
- Parents can do several practical things to support their child’s development, including encouraging the child to do what they can do; praising them when they succeed but overlooking their failures or bad behaviour; helping them to practise and develop basic living skills such as washing themselves and greeting others appropriately.
- Enuresis is a common childhood problem that often improves with time and without the need for intervention. In children without a physical cause for enuresis, the best approach is to emphasise support of the child rather than criticism or punishment.
- Psychical, emotional or sexual abuse of children can have a long-lasting emotional impact. When you suspect child abuse you should, through tactful action, try all you can to stop the abuse.
- Conduct disorder, depression, anxiety, autism and ADHD are other childhood behavioural conditions that you should look out for in your community. Most of these conditions are helped by firm supportive guidance from family members and teachers.
Self-Assessment Questions (SAQs) for Study Session 17
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
SAQ 17.1 (tests Learning Outcomes 17.1, 17.3 and 17.5)
Indicate whether the following two statements are true or false and in each case explain why.
A Intellectual disability is incurable and neither parents nor you can do much to help.
B Beating a child is an important part of disciplining a child and will not affect the child’s development.
Answer
A is false. It is true that there is no cure for intellectual disability (ID), but there is a range of things that both you and the child’s parents can do to help. An example of this is provided in Section 17.2.2, in the case study of Tessema. This case study stresses the importance of your role in the assessment and identification of ID. You can also help the parents to understand this condition, and encourage and educate them to provide appropriate care and stimulation. A list of tips and suggestions you can offer parents is provided in Box 17.1. Your role in the prevention of ID is discussed in Box 17.2.
B is false. Beating a child is a form of child abuse (see Section 17.4). Frequent and severe physical abuse of a child can cause damage to the child’s physical and emotional development. Sometimes children may be punished or beaten so severely that they may sustain serious physical injuries including broken bones. This can also lead to delays in intellectual development.
SAQ 17.2 (tests Learning Outcomes 17.1, 17.2 and 17.4)
Childhood enuresis is a relatively common problem. What can you do to support the child and their family?
Answer
Your role is mainly in supporting the child and educating parents about the most effective approaches to managing the problem of enuresis (see Box 17.4). The main point to stress to parents is that punishment does not work and can make the condition worse because it can undermine the child’s confidence. Instead, parents should praise success and ignore failure. Referral for treatment is generally only necessary when there are some underlying physical conditions, such as infections, diabetes and problems with the bladder.
SAQ 17.3 (tests Learning Outcomes 17.6)
In most instances children with behavioural problems do not require referral to the nearest healthcare facility. What factors would make you decide that referral was necessary?
Answer
Most childhood behavioural problems tend to improve with time. However, in cases of serious childhood problems specialist input is needed. Referral is necessary if you suspect there may be underlying health problems such as epilepsy, or evidence of conduct disorder, autism, attention deficit hyperactivity disorder (ADHD) and/or depression. Even children with these conditions may not require medication, but the specialist input can help in giving families and teachers firm guidance in how to support the child.