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Risk factors for child mental health problems

The presence of risk factors can alert the GP to probe more carefully for the symptoms of a psychiatric disorder in a child with a non-specifi c presentation. Important family factors include parental physical and mental disorder and domestic violence. The risk may be mediated through a number of routes: parenting may be suboptimal, children may be expected to take on increased responsibilities including caring for parents, or children may witness severe violence. Adequate parenting requires the provision of appropriate support and nurturing, the encouragement to develop independence while simultaneously providing adequate supervision, with clear boundaries and contingent reinforcement (praise or punishment) for behaviour.

Living in poverty, unsuitable housing, or an unsafe neighbourhood are also risk factors for child psychiatric disorder, although the routes to disorder are not entirely clear. While environmental deprivation and danger may provide one source of risk, these factors may also be associated with other characteristics of parents and family functioning that will not be immediately repaired by a change in family fi nancial or housing circumstances. Nevertheless, negative experiences, both family and externally based, may play an important role in initiating psychiatric symptoms. With increasing recognition of post-traumatic stress disorder in children, it is important to elicit any signifi cant life events or experiences.

Children are surprisingly reluctant to tell their parents about bullying at school or in their peer environment, and more sensitive areas of abuse may be even more diffi cult to discuss. Environmental triggers frequently play a role, but should be considered especially in children with a relatively sudden onset in the context of previously good functioning. Of course, chronic environmental threat will frequently produce a clinical picture of chronic psychiatric disorder. Family factors may also play a role in determining the outcome of disorder. Parental recognition of psychiatric symptoms plays a crucial role in determining referral to and attendance at mental health services. This divergence in opinion may stem from several routes. First, the child’s behaviour may differ in varying situations, so that reports from school of disruptive and antisocial behaviour may not coincide with parents’ perspective from home. Second, the same behaviour may be interpreted in different ways.

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