Headlines about physical and sexual violence towards and by children remind us that family relationships can go disastrously wrong, but the far wider problems of emotional and mental distress in childhood does not evoke a public outcry.

Children suffer when they feel that love is withdrawn or when they are humiliated, threatened with abandonment or made to feel that adult's fears and failures are their fault.

Many children and young people do not have continuing and harmonious relationships with parents and carers. Reasons for this often lie outside the control of the family, caused by a complex interaction between economic, environmental and social circumstances. but, when relationships are damaged for whatever reason, the child's emotional health and development is seriously threatened.

Children may respond by retreating from emotional contact or arm themselves with a mask of self reliance. Some take flight into illness, apathy, depression, rebellion, delinquency or aggression. Many struggle to find reliable adults with whom trusting relationships can be formed. Children who have been badly treated themselves often do not know how to relate to their own children and may even physically abuse them.

Research has shown that 20% of the United Kingdom's 12 million children suffer a degree of emotional and mental health problems, at least a third of whom experience continuing problems as adults.

To break this cycle of misery it is important to help the child and family as early as possible. The earlier the intervention the more long-lasting is the change achieved.

How are children's emotional and mental health problems recognised?
A healthy child has:

• a capacity to enter into and enjoy relationships
• the ability to learn from experience and use it appropriately
• the capability to play and learn appropriately to age and intellectual ability
• a developing moral sense of right and wrong
• ability to adapt behaviour within the context of age and circumstance

Pre-School Children
Symptoms in pre-school children are usually expressed through behaviour problems such as sleeplessness, over activity, anxieties over separation, tantrums and control problems. Pre-school boys show more problems than girls, particularly of over-activity. Pre-school girls are more likely to be troubled by fears.

Middle School Age Children
Symptoms are often expressed as conduct or emotional disorders and anti-social and aggressive behaviour like stealing and truancy. Boys are up to four times more likely than girls to show such behaviour. Symptoms of depression are present in 5% of children under 12 years.

Adolescence
Emotional and mental health disorders increase in adolescence and can be expressed in the most devastating ways. For example, self harm involves 3% of adolescents in their teenage years. Boys of 15-20 years are at greater risk of suicide, injury and criminal offending while depression is more common in girls.

Risk Factors
A risk factor is not a direct cause but may give rise to a probability. Young minds are affected in three ways:

The Child
Some children are born with conditions such as a learning disability. Others are born healthy but are damaged later, perhaps through drugs or alcohol. Risk factors include certain physical illnesses, genetic influences, developmental delay and a difficult temperament.

The Family
Some children are emotionally disturbed or physically hurt by family members, or allowed to be hurt by other people. Others are affected by family events such as bereavement. Some families have their own overwhelming problems and the needs of the child are neglected. Risk factors include parental conflict, family break down, physical, sexual or emotional abuse, parental psychiatric illness, parental criminality, alcoholism or personality disorder, death and loss of family or friends, rejecting or hostile relationships.

The Environment
Children need security and boundaries within which to thrive. Yet family composition is changing fast and socio-economic conditions fluctuate continually. These factors affect children in ways that are not fully understood and socio-economic status seems to play its part. For example, depression doesn't seem to be linked to social class, yet conduct disorders and eating disorders seem to be linked to social class. Risk factors include economic disadvantage, homelessness and discrimination.

Who are Child Psychotherapists?
Psychotherapy, in common with psychiatry and psychology, aims to assist individuals address their emotional problems.

Child psychotherapy is a "talking therapy" where children are helped to express their problems through language and play. Drugs and behaviour modification techniques are not used. Child psychotherapists make a unique contribution to clinical work by focusing on and advocating the child's point of view.

Child psychotherapists undergo a minimum of four years specialist postgraduate training. They often have backgrounds in teaching, psychology, nursing and social work. Personal analysis is essential to protect vulnerable children by monitoring the suitability of psychotherapists in training. Child psychotherapists support and advise other practitioners.

How can psychotherapy help?
Psychotherapy can be undertaken with children by themselves but is often part of a wider care programme. Child psychotherapists work in multi-disciplinary teams. They work with individual children, parents, families and groups in settings such as:

• mainstream and special schools
• day care centres for under 5s
• walk-in adolescent units
• mother and baby clinics
• special care baby units