There is disagreement around the mental health diagnosis and treatment of children. Controversy also exists about the ages at which a mental health diagnosis may be appropriate; the over medication of children with disabilities and the side effects of psychotropic medicines; the role of pharmaceutical companies in developing and recommending drugs for use by children; the various risks of failing to provide appropriate treatment; and the lack of resources for children and youth with mental healthcare needs.
There is also no consensus about how to refer to children with a mental health diagnosis. Do they have mental illness, mental health disabilities, emotional or behavioral disturbance? Or, are they demonstrating the effects of unaddressed trauma, as some therapists believe?
What is clear is that the mental and physical well-being of children who have experienced traumatic events is at risk. The more prolonged the trauma and the less support and treatment children receive, the higher the risk of long-term negative effects.
Medical practitioners sometimes divide trauma into “big T” and “little t” traumas. “Big T” traumas can include physical and sexual abuse and neglect, as well as severe car accidents, surgery, and other intrusive medical procedures. These are often events with huge impacts. But children with disabilities also experience daily “little t” traumas, including frequent and sometimes painful therapies; being excluded; neglect; humiliation; and lack of friends, autonomy, and choice. All these stressors can be traumatic and may significantly impact a child’s mental health and behaviors.
Other traumatic events that can affect children in profound ways include witnessing domestic violence and emotional abuse, racial trauma, inter-generational abuse, and living in homes and communities impacted by poverty.
Children with significant disabilities who have had fewer opportunities to make choices or cannot speak for themselves may communicate primarily through their actions and behaviors. These actions may be punished and diagnosed as a behavioral disorder, rather than recognized as a child's attempt to communicate unhappiness, fear, or frustration.
What You Might Notice
Children who have experienced abuse, neglect, and/or bullying are likely to have some symptoms of traumatic stress. Some of those children and youth will have been diagnosed with a mental-health related disorder.
Abuse and neglect can have significant impacts on children’s physical and mental health well into adulthood, according to studies on adverse childhood experiences (ACEs). Children who have experienced a number of traumatic events, particularly without parental or guardian support, can have short or long-term impacts of post-traumatic stress, anxiety and depression, according to the National Child Traumatic Stress Network. Adolescents who experience sexual assault/abuse may use high risk behaviors to cope, such as substance abuse, self-harm, and suicidal behaviors.
Some children will also develop symptoms of post-traumatic stress disorder (PTSD). PTSD is most common in children who have experienced severe, chronic, and/or interpersonal trauma such as physical or sexual abuse or severe neglect.
However, the NCTSN also emphasizes that children of all ages can and do recover from abuse with effective treatment and parent or guardian support. Children with any level of traumatic stress can benefit when the adults in their lives understand the role that trauma plays in their mental and physical well-being, and work to find the best ways to help them cope and heal.
Before Meeting the Child
Gather information from the school, counselor, caregivers, and others about the child’s history of traumatic events, diagnosis, and coping strategies, including self-care routines, self-harm, and addictions to alcohol, drugs, food, sex, nicotine, etc. Some of these coping strategies allow children and adults to survive difficult times, although they can have harmful consequences.
In addition to learning about a child's mental health history and/or diagnosis, learn from records and interviews how the child functions on a daily basis, and how they manage school, family, and friends.
Find out if there have been recent changes in the child’s reactions and behaviors, what medications they are taking and the possible side effects. Also ask if there are particular words, situations, or questions that might be distressing or triggering. Gather information about how to help the child best cope with any stress from the interview.
During the Meeting
Set the Stage
Structure the meeting. Explain what you will talk about and do and for how long. Be direct and clear about who you are and what your role will be.
Keep the meeting space free of distractions. Leave a clear path to the exit so the child does not feel trapped or cornered.
Ask if there is anything you can do to help the child feel more comfortable, and support them in controlling the situation as much as possible. However, because children who have experienced abuse may not routinely have their needs taken into account, they may have difficulty telling you what they need. Offer concrete choices: where to sit in the interview room, whether to sit or stand or pace, when to take a break, etc. (D. Velasco, personal communication, July 27, 2014).
Respond to the Child
Let the child or youth know that talking about this subject is difficult for most children and adults.
If the child withdraws, give them some time and space to process reactions.
If the child or youth is not talking, introduce another age-appropriate activity, such as drawing or playing with clay or Play-Doh. Then restart the conversation. Having something to touch can help children talk, think, and process. Have soft pillows and stuffed animals available for holding. Weighted blankets are also helpful for self-soothing.
If the child is depressed, anxious, has a poor tolerance for frustration, is showing impulsivity, does not recognize social cues, or is restless or irritable:
- Be direct and clear about what you are asking.
- Be reassuring and provide some structure to minimize anxiety.
- Establish an agenda and follow it.
- Recognize that a lack of emotion may not indicate a lack of interest.
- Avoid discussion when the child is fatigued or over-stimulated.
- Be flexible if the child is resistant. Confrontation can shut down thinking and make the child rigid.
If the child becomes agitated, consider allowing them to move about, pace, fidget, or jump in place, because it may help self-soothe. If the activity becomes disruptive or isn’t soothing, redirect the child back to the conversation.
Again, ask what you can do to make the child more comfortable. Offer a short break or provide more space.
- If the child seems volatile, but is still safe, provide a large enough physical space for them to be able to calm down.
- If the child's agitation continues, reschedule the meeting.
- If the child is getting distressed, consult your notes (if available) for information on how to best help them become calm.
- If the child is raging or experiencing overwhelming distress and this distress does not decrease with time, seek assistance from the child’s caregiver or support person or a qualified mental health practitioner.
Keep these basics in mind when supporting children in distress:
- Repeatedly check in and assess your own level of calmness and stress.
- If you identify signs of distress within yourself, actively ground and stabilize your body and nervous system through a quick meditation or another means.
- Be mindful of your size, posture, and physical orientation to the child.
- Keep your voice calm and low, and notice how your eye contact, facial expressions, tone of voice, and gestures impact the child.
- Be attuned to the child’s needs during times of stress and transition.
(Adapted in part from Levine & Kline, 2007; and James, 1996.)
If possible, refer the child for trauma-informed therapy for ongoing support.
Work with local mental health providers to conduct a comprehensive and trauma-informed assessment that includes information on symptoms, functioning, strengths, and resilience.
Offer information and resources to the child’s caregivers to increase their capacity to support the child in recovery.