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MyFreud

By , Editorial Team Published

Child Mental Health: Signs and When to Act

Half of all mental health conditions begin before fourteen and most are missed. How to tell an ordinary difficult phase from something worth assessing.

4 min read

Pop-art illustration of a young child seen in profile, looking out through a window at trees.

Key takeaways

  • Most conditions start young and are identified late. Around half of all lifetime mental health conditions have begun by the mid-teens, and the gap between onset and treatment is routinely measured in years rather than months.
  • Three questions separate a phase from a problem: how long it has lasted, how many settings it shows up in, and what it is stopping the child doing. One of the three alone is weak evidence.
  • In children, distress often does not look like sadness. It looks like irritability, stomach aches and headaches, refusing to go places, sleep falling apart, or a sudden collapse in schoolwork.
  • Quiet children get missed and loud children get misread. Referral follows disruption rather than distress, which is why an anxious child who complies is often the last one anybody worries about.
  • Child therapies work, and the effect is real without being transformative. Decades of trials show meaningful average benefit, with the parent or carer part of the treatment rather than an audience to it.

Most mental health conditions begin in childhood or adolescence, and most are identified years after they begin. Solmi and colleagues pooled 192 studies and put the peak age of onset in the mid-teens, with a substantial share of lifetime conditions already under way well before that. [solmi-2022-onset] This guide covers what distress looks like in a child, which children get missed and why, and the three questions that separate an ordinary difficult stretch from something worth assessing.

The three questions

A difficult fortnight is a difficult fortnight. What distinguishes it from something that needs looking at is not intensity, which is the instinctive measure and a poor one, but the combination of three things.

How long has it lasted? Months rather than weeks. Children have bad patches, and most resolve.

How many settings does it show up in? Home, school, and with friends, rather than one place. A child who is fine everywhere except one classroom is telling you something about that classroom.

What is it costing? Whether it is stopping them doing things they used to do or want to do. This is the most useful of the three and the one adults most often skip, because it is about function rather than feeling.

One of the three alone is weak evidence. All three pointing the same way is a reason to describe the pattern to a doctor, and describing a pattern costs very little.

What separates a phase from a problem Illustrative
0 25 50 75 100 Weight of evidence 15 Under 2 weeks 35 2-4 weeks 65 1-3 months 90 Over 3 months
0 25 50 75 100 Weight of evidence 25 One setting 60 Two settings 92 Everywhere
0 25 50 75 100 Weight of evidence 20 Nothing yet 50 One activity 78 Friendships 95 School attendance

The duration, pervasiveness and impairment criteria that run through child diagnostic frameworks, as summarised by Polanczyk and colleagues (2015). Values illustrate the relative weight of each signal rather than reporting measured scores.

Distress in a child rarely looks like sadness

The adult picture of depression, meaning visible low mood and tearfulness, is not the usual childhood presentation, and expecting it is one of the main reasons things get missed.

Irritability is frequently the dominant mood. A child who has become snappy, hard to please and quick to anger may be describing something other than bad behaviour, and the response that treats it purely as behaviour addresses the surface.

Physical symptoms are common and are real. Stomach aches, headaches and exhaustion are produced by the stress response through ordinary physiology, so “there is nothing wrong with you” is both inaccurate and the fastest way to stop a child telling you things.

Loss of interest, sleep changes, a drop in schoolwork and withdrawal from friends round out the picture. In younger children there may also be regression, meaning a return to behaviours they had already grown out of.

Polanczyk and colleagues put the worldwide prevalence of any mental disorder in children and adolescents at a level that makes several children in any given classroom the expected case rather than the exception. [polanczyk-2015-prevalence]

Which children get missed

Referral follows disruption, not distress, and that single fact explains most of the pattern.

A child whose anxiety makes them compliant, careful and reluctant to ask for anything creates no problem for any adult, so no adult raises it. They are frequently described as no trouble at all, which is accurate and is the reason nobody looked. The same mechanism under-identifies girls in ADHD, where an inattentive presentation produces a daydreaming child rather than a disruptive one.

The error runs the other way too. A child whose distress comes out as anger is read as a behaviour problem, gets a behavioural response, and the driver goes untouched. Our guides to school anxiety and bullying cover two of the most common drivers that present this way, and our guide to gender dysphoria covers another, where the distress is frequently attributed to the identity rather than to how a young person is being treated.

What to describe at an appointment

For a parent or carer. This is not a test and cannot diagnose anything. It is a way of turning a general worry into the specifics a doctor can act on.

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What treatment looks like

Weisz and colleagues pooled five decades of trials of psychological therapy for young people and found meaningful average benefit, alongside the honest finding that effects are moderate rather than dramatic and vary considerably by condition and context. [weisz-2017-fivedecades]

What recurs in the approaches that work: they are structured rather than open-ended, time-limited, teach specific skills, and involve the parents or carers as part of the treatment. That last point is the one families are most often surprised by. For younger children especially, work with the adults around the child frequently carries more of the effect than work with the child alone, which is not a comment on the parents but a fact about who controls a young child’s environment. Our guide to parenting and mental health covers that side.

When to seek help

Speak to a doctor if the three tests point the same way, if something has changed markedly and stayed changed, or if your own sense that something is wrong has persisted even without being able to name it. Parents notice changes well before they can articulate them, and that instinct is worth acting on rather than waiting to justify.

Seek help promptly rather than watching for longer if there is self-harm, if a child talks about not wanting to be alive, if eating or drinking has changed substantially, or if they have stopped attending school altogether.

If you are in crisis, contact your local emergency services or a crisis helpline.

Frequently asked questions

How do I know if it is a phase or something more?

Three tests, and the useful signal is when all three point the same way. Duration: a difficulty that has run for months rather than a fortnight. Reach: it appears in more than one setting, so at home and at school and with friends rather than only in one place. Cost: it is stopping the child doing things they used to do or want to do. A child who is anxious about one thing for two weeks is doing something ordinary. A child whose worry has lasted three months, follows them everywhere and has cost them their activities has crossed into territory where an assessment helps. Age matters too, since behaviour that is developmentally expected at four is informative at eleven.

What does depression look like in a child?

Frequently not like sadness, which is the main reason it is missed. Irritability is often the dominant mood rather than low mood, so a child who has become snappy and impossible to please may be describing something other than bad behaviour. Physical complaints are common and real: stomach aches, headaches and tiredness produced by genuine physiological mechanisms rather than invented. Other signs include losing interest in things that used to matter, sleep changing markedly in either direction, a drop in schoolwork, and withdrawal from friends. In younger children it can also show as regression, meaning a return to behaviours they had grown out of.

Which children get missed?

Quiet ones, overwhelmingly, because referral follows disruption rather than distress. A child whose anxiety makes them compliant, eager to please and reluctant to ask for anything generates no problem for any adult to notice, so nobody notices. The same pattern under-identifies girls in conditions like attention deficit hyperactivity disorder, where the inattentive presentation produces a daydreaming child rather than a disruptive one. The reverse error also happens: a child whose distress comes out as anger is read as a behaviour problem and gets a behavioural response, which addresses the surface and leaves the driver untouched.

What treatments work for children?

Psychological therapies for children and adolescents have been tested extensively over several decades and show meaningful average benefit, with the honest caveat that the average effect is moderate rather than dramatic and that outcomes vary considerably. What recurs in the approaches that work is that they are structured, time-limited, teach specific skills, and involve the parents or carers as part of the treatment rather than as an audience. For younger children in particular, work with the adults around the child often carries more of the effect than work with the child alone.

When should I speak to someone?

When the three tests above all point the same way, when something has changed markedly and stayed changed, or when your own judgement says something is wrong even if you cannot articulate why. That last one is worth taking seriously: parents notice changes long before they can name them, and describing a pattern to a doctor is a low-cost step. Seek help promptly rather than waiting if there is self-harm, if the child talks about not wanting to be alive, if they have stopped eating or drinking normally, or if they have stopped going to school altogether.

References

  1. 1.Solmi M, Radua J, Olivola M, Croce E, Soardo L, Salazar de Pablo G, et al. ( 2022). Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry.
  2. 2.Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA ( 2015). Annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry.
  3. 3.Weisz JR, Kuppens S, Ng MY, Eckshtain D, Ugueto AM, Vaughn-Coaxum R, et al. ( 2017). What five decades of research tells us about the effects of youth psychological therapy: a multilevel meta-analysis and implications for science and practice. American Psychologist.