Psychiatry — Child and Adolescent Mental Health, NMC MBBS licence examination syllabus (Nepal Medical Council).
Child and adolescent mental health
Children rarely announce distress. They show it, or they ache.
Two related problems sit in this chapter. The first is developmental delay, where the clinical task is deciding whether a child who is behind needs investigation or reassurance. The second is psychological distress in children and adolescents, which almost never presents as a complaint about mood — it presents as irritability, school refusal, falling grades, or a stomach ache that has been investigated three times.
What connects them is that both are picked up by people who are watching, and missed by people who are only listening to the presenting complaint.
🩺 Where this lives: Most mental illness that lasts a lifetime begins before adulthood, which makes adolescence the single highest-value point for recognition — and the age group most likely to fall between paediatric and adult services. Adolescents are also the group least likely to volunteer distress to a doctor, particularly where mental illness carries stigma or where the parent is in the room. Seeing a young person alone for part of the consultation, having explained confidentiality and its limits, changes what you are told.
💡 A note on milestones and drugs. This chapter deliberately gives no milestone ages. Published ages differ between references and between the charts in national use, and a student reproducing the wrong set would be marked wrong. What is taught is the structure — the four domains, global versus isolated delay, and the red flags — with ages taken from the chart in current use. It also gives no doses or named agents: prescribing in this group is specialist and weight-based. Related material sits in the Depression and Anxiety, Risk Assessment, Ethics and Paediatric Nutrition chapters.
The four domains of development
Assessment is structured by domain because the pattern of delay points to the cause. Delay in one domain suggests something specific to that system — which is why every child with speech delay needs a hearing test and every child with fine motor delay needs vision assessed, before anything more elaborate is considered. Delay across two or more domains is global developmental delay and suggests a broader cause.
HOW TO THINK ABOUT A CHILD WHO IS BEHIND
1. IS IT ONE DOMAIN OR SEVERAL?
ISOLATED delay → look at that system first.
Speech delay → HEARING, always.
Fine motor delay → VISION.
Gross motor delay → neuromuscular assessment.
GLOBAL delay → two or more domains, suggesting a
broader cause.
2. IS THE CHILD PROGRESSING, STATIC, OR REGRESSING?
Progressing slowly is different from not progressing,
and both are entirely different from LOSING skills.
3. WAS THE CHILD PRETERM?
Correct for prematurity when assessing a young infant,
per the convention in local use.
4. WHAT ELSE IS IN THE HISTORY?
Pregnancy and birth, neonatal problems, hearing and
vision, seizures, family history, and the child's
environment — stimulation, nutrition and neglect all
affect development.
AND ALWAYS EXAMINE: growth, head circumference, a
neurological examination, and a look for dysmorphic
features.
Milestone ages come from the chart in current national
use — not from memory.
Red flags
💡 Exam angle: regression is the answer to a great many questions in this area. A child who is slow to acquire a skill may simply be slow; a child who loses a skill they already had is never normal and needs urgent assessment rather than review in six months. Note also the value of parental concern: parents detect real problems earlier than clinicians, and "I think he can't hear me" is a finding, not an anxiety to be soothed.
How distress presents
Two presentations are worth recognising immediately. The first is irritability rather than sadness — a depressed child is often described by the family as difficult, rude or badly behaved rather than as unhappy. The second is somatisation: recurrent abdominal pain and headaches that are genuinely felt, repeatedly investigated, and never explained. Both are commonly met with either investigation or discipline, when what is needed is a question about what is happening at home and at school.
Adolescents
TALKING TO AN ADOLESCENT
SEE THEM ALONE for part of the consultation where age and
circumstances permit. What a young person will say with a
parent present is not the whole story.
EXPLAIN CONFIDENTIALITY AND ITS LIMITS FIRST. Something
like: what you tell me stays between us, unless I am
worried that you or someone else is at serious risk — and
if that happens I will tell you before I tell anyone else.
Promising absolute secrecy is a promise you cannot keep,
and breaking it destroys the relationship entirely.
ASK ACROSS THEIR LIFE, not just about symptoms: home,
education and work, activities, substances, relationships,
mood and sleep. Structured frameworks for this exist and
are worth using.
ASK DIRECTLY ABOUT SELF-HARM AND SUICIDAL THOUGHTS.
Asking does not increase risk — this is covered in the
Risk Assessment chapter, and applies just as much here.
AND REMEMBER THE OVERLAP: substance use, low mood and
self-harm cluster together in this age group, so finding
one is a reason to ask about the others.
Safeguarding
💡 Exam angle: the features that should raise concern are worth learning precisely, because they are what an examiner will describe: an explanation that does not fit the injury, an injury inconsistent with the child's developmental stage (a bruise in a baby not yet mobile), delayed presentation, an account that changes between tellings, repeated attendances, and a frightened or withdrawn child. The key principle is that you do not need to be certain — concern is enough to document carefully, examine fully and escalate.
Clinical reasoning: four presentations
🔍 Case 1 — a child who has lost words
PresentationA toddler who had around a dozen clear words six months ago now uses almost none, and has become withdrawn. The family are told children develop at different rates and to return in six months.
The critical featureHe has lost skills he already had.
ReasoningRegression is always abnormal. It is entirely different from slow acquisition and requires urgent assessment rather than watchful waiting.
AnswerRefer for urgent paediatric developmental assessment, check hearing, and take a full history and examination looking for a cause.
🔍 Case 2 — the stomach ache with no cause
PresentationA 10-year-old has attended four times in three months with abdominal pain. Investigations are normal each time. Her mother mentions she has been refusing school. A fifth round of tests is planned.
PatternSomatisation with school refusal.
ReasoningRecurrent unexplained pain with school refusal in a child of this age is a common presentation of psychological distress. The pain is genuinely felt; further tests will not find its cause.
AnswerTake a careful history of home and school — including bullying, family conflict, bereavement and abuse — see her alone for part of it, and address the cause rather than repeating investigations.
🔍 Case 3 — "he's just being difficult"
PresentationA 15-year-old is brought by his parents because he has become rude, irritable and withdrawn, his grades have collapsed and he no longer sees friends. They ask for advice on discipline. The consultation takes place entirely with the parents present.
Two issuesIrritability as a presentation of depression, and no opportunity to speak alone.
ReasoningDepression in adolescence commonly presents as irritability and behaviour change rather than expressed sadness. Withdrawal from friends and falling grades are functional decline, not misbehaviour.
AnswerSee him alone for part of the consultation, explain confidentiality and its limits, ask across his life, and ask directly about self-harm and suicidal thoughts.
🔍 Case 4 — a bruise that does not fit
PresentationA 4-month-old, not yet rolling or crawling, is brought with bruising. The account is that he rolled off a bed, and the details change between tellings. Presentation was delayed by two days. The clinician is uncertain and reluctant to cause offence.
Concerning featuresInjury inconsistent with development, changing story, delayed presentation.
ReasoningAn infant who cannot yet roll cannot roll off a bed. The explanation does not fit, and uncertainty is not a reason to do nothing — you do not need to be certain.
AnswerExamine fully, document carefully in the exact words used, and escalate to a senior clinician and safeguarding per local procedure. The child's safety comes before the relationship with the family.
Commonly confused
Confusion
The distinction
Why it matters
Slow acquisition vs regression
Losing a skill already gained
Regression is always abnormal and urgent.
Global vs isolated delay
Two or more domains versus one
Isolated delay points to one system.
Speech delay vs hearing loss
Test hearing in every case
A treatable and commonly missed cause.
Irritability vs misbehaviour
Depression in children often looks like rudeness
Discipline is offered instead of help.
Somatic symptoms vs "nothing wrong"
The pain is genuinely felt
More tests will not find the cause.
Confidentiality vs absolute secrecy
Explain the limits before starting
A promise you cannot keep destroys trust.
Certainty vs concern in safeguarding
Concern is enough to act on
Waiting for proof leaves a child at risk.
Bruise in a mobile vs immobile infant
Injury must fit developmental stage
An immobile baby cannot roll off a bed.
Rapid revision
MUST-KNOW FACTS
1. Four domains: GROSS MOTOR, FINE MOTOR AND VISION, SPEECH AND HEARING, SOCIAL.
2. GLOBAL delay = two or more domains affected.
3. ISOLATED delay = one domain, most often speech.
4. CHECK HEARING in every child with speech delay.
5. Check VISION in fine motor delay.
6. REGRESSION — losing acquired skills — is ALWAYS abnormal.
7. Regression needs urgent assessment, never watchful waiting.
8. Other red flags: no response to sound, no eye contact, asymmetry.
9. Very early hand preference suggests a problem on the other side.
10. PARENTAL CONCERN is a sensitive screening tool — take it seriously.
11. Correct for PREMATURITY when assessing a young infant.
12. Examine growth, head circumference, neurology and dysmorphic features.
13. Take milestone AGES from the chart in current national use.
14. Children present distress as IRRITABILITY, not stated sadness.
15. Also as behaviour change, school refusal and falling grades.
16. Or as SOMATIC symptoms — recurrent abdominal pain and headache.
17. Somatic symptoms are genuinely felt; more tests will not explain them.
18. Always consider context: bullying, bereavement, conflict, ABUSE.
19. Most lifelong mental illness begins BEFORE ADULTHOOD.
20. SEE ADOLESCENTS ALONE for part of the consultation.
21. EXPLAIN CONFIDENTIALITY AND ITS LIMITS before starting.
22. Never promise absolute secrecy.
23. Ask across their life: home, education, activities, substances, mood.
24. ASK DIRECTLY about self-harm and suicidal thoughts.
25. Asking about suicide does NOT increase risk.
26. Substance use, low mood and self-harm cluster together.
27. Safeguarding concern: explanation that DOES NOT FIT the injury.
28. Injury inconsistent with the child's developmental stage.
29. Also delayed presentation, changing story, repeated attendance.
30. DOCUMENT in the child's own words, examine fully, escalate.
31. YOU DO NOT NEED TO BE CERTAIN — concern is enough to act.
32. The child's safety comes before the relationship with the family.
💡 Exam angle: four ideas answer most questions here. Regression is always abnormal. Speech delay means test the hearing. Irritability in a child may be depression. And in safeguarding, concern — not certainty — is the threshold for acting.
Syllabus points
The four developmental domains
Global versus isolated delay
Why speech delay means testing hearing
Progressing, static or regressing
Why regression is always abnormal
Other developmental red flags
Parental concern as a screening tool
Distress presenting as irritability
Somatisation and school refusal
Seeing adolescents alone
Explaining the limits of confidentiality
Asking directly about self-harm
Recognising possible abuse or neglect
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