Child-protection and safety notice: A child’s behaviour may be communication of unmet developmental, medical, emotional or safeguarding needs. Do not punish, shame or diagnose from one encounter. Suspected abuse requires immediate safety planning, confidential assessment and reporting/referral according to Ugandan law and facility policy.
Learning objectives
- Describe normal development using biological, cognitive, psychosocial and psychosexual frameworks.
- Recognise developmental delay, intellectual disability, autism spectrum disorder, ADHD and disruptive behaviour disorders.
- Assess a child or adolescent across home, school, peer and community settings.
- Identify trauma, neglect, exploitation, bullying, self-harm and abuse, and respond safely.
- Use caregiver skills training, school support, behavioural interventions and carefully selected medicines.
1. Development is multidimensional
Development is influenced by genes, nutrition, illness, sleep, attachment, stimulation, language, culture, schooling, poverty, disability inclusion and safety. Milestones are ranges, not a competition. Regression—loss of a previously acquired skill—is always clinically significant and requires prompt assessment.
| Domain | Assess | Red flags |
|---|---|---|
| Gross motor | Head control, sitting, crawling, standing, walking, coordination and strength. | Marked asymmetry, persistent toe-walking with other signs, loss of skills or inability to bear weight. |
| Fine motor/adaptive | Reaching, grasping, drawing, feeding, dressing and self-care. | Persistent hand preference very early, severe clumsiness, loss of skills or inability to use both hands. |
| Language/communication | Babbling, gestures, words, sentences, comprehension, reciprocity and pragmatic communication. | No response to sound/name, no gestures or meaningful words when expected, loss of language or inability to understand simple communication. |
| Social/emotional | Attachment, shared enjoyment, eye gaze, play, empathy, friendships and emotional regulation. | No social reciprocity, extreme withdrawal, persistent severe aggression, self-injury or regression. |
| Cognition/executive function | Attention, memory, problem solving, learning and flexibility. | Global learning difficulty, major discrepancy between potential and school performance or progressive decline. |
2. Developmental theories in examination answers
| Theorist | Key ideas | Clinical use and limitation |
|---|---|---|
| Erikson | Psychosocial tasks: trust vs mistrust; autonomy vs shame; initiative vs guilt; industry vs inferiority; identity vs role confusion; intimacy, generativity and integrity in later life. | Helps explore the child’s social context and developmental task; stages are not rigid or culturally universal. |
| Piaget | Sensorimotor, pre-operational, concrete operational and formal operational cognitive development. | Guides communication and teaching; children vary and can reason differently across contexts. |
| Freud | Psychosexual stages—oral, anal, phallic, latency and genital. | Historically important for theory; do not use as a stand-alone diagnostic model or to blame caregivers. |
| Attachment theory | Early relationships influence safety, emotion regulation and expectations of others. | Supports caregiver-sensitive assessment; avoid simplistic labels such as “bad parenting”. |
3. Comprehensive child and adolescent assessment
Interview in layers
- Child’s voice: speak at the developmental level, use play/drawing, ask what is difficult and what they want to change.
- Caregiver history: pregnancy, birth, neonatal illness, development, nutrition, sleep, seizures, medical conditions, medicines, family history and strengths.
- Function: home routines, school attendance/attainment, relationships, self-care, play, chores, online activity and community participation.
- Context: housing, food insecurity, disability access, violence, bullying, migration, bereavement, cultural beliefs and caregiver mental health.
- Safety: abuse, neglect, exploitation, self-harm, suicidal thoughts, dangerous impulsivity, weapons, sexual risk and harm to others.
Observe interaction, play, language, attention, activity, eye contact, sensory responses, repetitive behaviour, mood, thought content and neurological signs. Obtain teacher reports and school records with consent. Do not rely on a single checklist or diagnose solely because a child is energetic or shy.
4. Developmental disorders
Intellectual disability
Intellectual disability involves limitations in intellectual functioning and adaptive behaviour beginning during the developmental period. Adaptive functioning—communication, self-care, social participation, learning and practical safety—determines support needs more than an IQ number alone.
- Assess hearing, vision, epilepsy, cerebral palsy, genetic/syndromic features, nutrition, thyroid/metabolic disease, prenatal infections, birth injury and environmental deprivation.
- Use developmental and adaptive assessments appropriate to language and culture; formal cognitive testing should be performed by trained professionals.
- Provide caregiver skills training, communication supports, inclusive education, physiotherapy/occupational therapy, seizure care, sexuality education and transition planning.
- Protect against bullying, neglect, exploitation, unnecessary restraint and sexual abuse. Presume capacity to communicate and participate in decisions with support.
Autism spectrum disorder
Autism is a neurodevelopmental condition characterised by persistent differences in social communication/interaction and restricted, repetitive patterns of behaviour, interests or sensory processing, present from early development and affecting function. Presentation varies widely; some people speak fluently while having substantial sensory or social support needs.
- Ask about early social reciprocity, gestures, pretend play, language, repetitive movements, intense interests, sensory sensitivities and change intolerance.
- Screen hearing, vision, epilepsy, sleep, gastrointestinal symptoms, ADHD, anxiety, depression and intellectual disability.
- Use predictable routines, visual supports, communication aids, environmental adaptation, caregiver skills training and inclusive school support.
- Do not use antipsychotics to treat core autism features. They may be considered short-term by a specialist for severe aggression or irritability after behavioural and environmental measures, with metabolic and neurological monitoring.
Attention-deficit/hyperactivity disorder (ADHD)
ADHD involves developmentally inappropriate inattention and/or hyperactivity-impulsivity that is persistent, begins in childhood, occurs in more than one setting and impairs functioning. Consider sleep deprivation, anxiety, trauma, learning difficulty, hearing/vision problems, seizures, thyroid disease, substance use and chaotic environments.
- Collect parent and teacher information, school functioning and impairment; do not diagnose from a short clinic observation.
- First-line care includes psychoeducation, caregiver behaviour training, classroom structure, seating and task adaptations, exercise, sleep routine and treatment of comorbidity.
- Where specialist assessment and local regulation permit, methylphenidate may be used. A common educational starting example is 5 mg once or twice daily, titrated cautiously; check blood pressure, pulse, weight, appetite, sleep, tics, mood, misuse/diversion and cardiac history. Exact formulations and doses vary.
- Atomoxetine or other options may be considered by specialists. Do not prescribe stimulants when there is uncontrolled psychosis, mania or significant cardiovascular risk without specialist review.
5. Behavioural and emotional disorders
Oppositional defiant and conduct problems
Oppositional behaviour is persistent angry/irritable mood, arguing, defiance or vindictiveness beyond developmental expectations. Conduct disorder involves repetitive violation of others’ rights, major rules or safety. Assess trauma, harsh punishment, bullying, neglect, ADHD, learning difficulty, substance use, depression, emerging psychosis and peer influence.
- Use collaborative caregiver programmes: clear instructions, predictable routines, praise, consistent non-violent consequences and supervision.
- Work with school and community; address sleep, nutrition, learning support, bullying and unsafe peers.
- Antipsychotics are not routine treatment for conduct problems. A specialist may consider short-term treatment for severe aggression after medical/trauma assessment, with informed consent and metabolic monitoring.
Depression, anxiety and self-harm in adolescents
Look for irritability, withdrawal, falling grades, somatic complaints, sleep/appetite change, hopelessness, self-harm, substance use and suicidal thoughts. Ask directly and privately. Treat bullying, abuse, grief, trauma and family conflict; offer psychological therapy and safety planning. Antidepressants in children/adolescents require specialist or experienced supervision, close early review for activation and suicidality, and limited dispensing when overdose risk exists.
Eating, elimination and sleep problems
Assess restrictive eating, binge/purge behaviour, weight change, body-image distress, constipation, enuresis, encopresis, nightmares, sleepwalking, delayed sleep phase and sleep-disordered breathing. Check growth, hydration, glucose, electrolytes and safeguarding where indicated. Avoid shame; use behavioural routines and medical/psychological referral.
6. Child maltreatment: recognition and response
WHO defines child maltreatment as physical or emotional ill-treatment, sexual abuse, neglect, negligence or exploitation causing actual or potential harm in a relationship of responsibility, trust or power. A disclosure may be partial, delayed or inconsistent because of fear, shame, developmental ability or threats.
Possible indicators
- Unexplained or patterned bruises, burns, fractures, bite marks, genital injury, sexually transmitted infection or pregnancy.
- Failure to thrive, poor hygiene, untreated illness, frequent absences, unsafe supervision or lack of food.
- Sudden regression, sleep disturbance, sexualised behaviour, fear of a person, hypervigilance, dissociation, aggression, withdrawal or self-harm.
- Caregiver explanations inconsistent with the child’s developmental ability, delay in seeking care or repeated injuries.
Trauma-informed interview
- Ensure privacy and immediate safety; separate the child from a suspected perpetrator without creating further danger.
- Use open prompts: “Tell me what happened.” Avoid leading, repeated or suggestive questions.
- Believe and support without promising secrecy: “I’m glad you told me. I need to involve people who can help keep you safe.”
- Record the child’s exact words, demeanour, injuries and times; do not investigate beyond clinical need.
- Provide medical care, emergency contraception/HIV PEP and STI care when indicated, psychological first-line support and urgent safeguarding referral/reporting according to Uganda policy.
7. Treatment plan across settings
| Need | Intervention | Measure progress |
|---|---|---|
| Developmental delay/disability | Caregiver skills training, communication aids, therapy, inclusive education and community-based rehabilitation. | Participation, adaptive skills, communication and caregiver confidence. |
| ADHD/behaviour | Parent training, classroom plan, sleep/exercise, individual therapy and specialist medicine when indicated. | Function at home/school, safety, attendance and relationships—not only symptom counts. |
| Autism | Environmental adaptation, predictable routines, communication support, sensory accommodations and treatment of comorbidity. | Comfort, communication, self-care, participation and reduced distress. |
| Trauma/abuse | Safety, medical care, child-protection referral, trauma-focused psychological care and stable caregiving. | Safety, sleep, mood, school participation and recovery from trauma symptoms. |
8. Medication safety in children
- Use weight-based dosing and the correct formulation; check weight, allergies, renal/hepatic function, pregnancy potential in adolescents and interactions.
- Explain purpose, expected benefit, adverse effects, storage and what to do when a dose is missed. Secure medicines where overdose or diversion is a risk.
- Monitor growth, blood pressure, pulse, movement disorders, prolactin/metabolic effects, mood activation and suicidality according to the medicine.
- Do not use sedatives, antipsychotics or antidepressants as a substitute for a safe environment, caregiver intervention or protection from abuse.
Clinical cases
Case 1 — language regression: A 2-year-old loses words and stops responding to name. Action: urgent developmental assessment, hearing test, neurological review for seizures/regression and caregiver support; do not reassure that the child will “grow out of it.”
Case 2 — school inattention: A 9-year-old is disruptive only in a crowded, poorly lit classroom and has poor vision. Action: correct vision/environment and assess learning before diagnosing ADHD.
Case 3 — suspected abuse: A child has bruises in different healing stages and a changing caregiver story. Action: stabilise, private child-centred history, document objectively, examine appropriately and activate safeguarding/reporting; do not send the child back into danger without a safety plan.
Case 4 — adolescent self-harm: A 15-year-old cuts their arm after online bullying and says life is pointless. Action: treat injury, ask directly about suicidal intent/means, ensure supervision and safety planning, address bullying, involve safe caregivers and arrange urgent mental-health follow-up.
Quick self-test
- Why is regression more concerning than a stable developmental delay?
- What evidence is needed before diagnosing ADHD?
- Name three supports for autistic children that do not attempt to change their identity.
- What are the first principles when a child discloses abuse?
- Why should conduct problems prompt assessment of trauma and learning difficulty?
Answers
- Loss of acquired skills may indicate epilepsy, neurological disease, infection, metabolic disease or severe psychosocial stress and needs prompt assessment.
- Persistent developmentally inappropriate symptoms beginning in childhood, impairment in at least two settings, collateral information and exclusion of alternative explanations.
- Predictable routines, visual/augmentative communication, caregiver skills training, sensory accommodations, inclusive education and treatment of comorbidities.
- Ensure safety, listen with open prompts, avoid leading questions, validate without promising secrecy, document exact words and activate medical/safeguarding referral.
- Trauma, abuse, ADHD, learning disability, sleep problems and environmental stress can present as defiance or aggression and require different treatment.
Key take-home messages
- Assess the child in context across development, health, family, school, peers and safety.
- Developmental and behavioural diagnoses require impairment, persistence, collateral information and exclusion of medical/psychosocial alternatives.
- Caregiver skills training, school accommodations and community rehabilitation are core treatments.
- Regression, self-harm, severe aggression, suspected abuse and suicidal thinking require urgent action.
- Protect children from stigma, coercion and violence; document and refer according to local safeguarding policy.
References and further reading
- World Health Organization. Child and adolescent mental disorders: mhGAP evidence centre: WHO mhGAP child/adolescent resource.
- WHO mhGAP training manual. Child and adolescent mental and behavioural disorders: WHO training module.
- World Health Organization. Responding to child maltreatment: a clinical handbook: WHO clinical handbook.
- World Health Organization. WHO guidelines for the health sector response to child maltreatment: WHO guidance.
- World Health Organization. Caregiver skills training for developmental disorders: WHO recommendation.
Local-practice reminder: Use current Uganda child-protection, mental-health, education and medicines guidance. Suspected abuse is a safeguarding emergency; seek senior and statutory support.
