Growing up in non-traditional homes is the new normal. Child therapists can no longer argue that children are better served by living in a nuclear family unit with a biological cisgender mother, a cisgender father and a sibling or two. As newer and more advanced forms of assisted reproductive techniques come into existence, children are now given life when it would have been impossible before. Adopted children of different races, children from surrogates and donor eggs and sperm (with or without co-parents), single-parent families and same-sex-parent families are all celebrated as a wonderfully diverse aspect of the world today. The twenty-first century is proudly diversified and profoundly complex. Child psychology has, to some extent, embraced this with flexibility and adaptability. Rather than viewing anything that diverges from the old norm as being pathological, most clinicians try to view the world through the child's eyes and the eyes of her caregivers too.

In my literature search for this chapter, I discovered an important emerging theme that corresponds to what I have noticed in my own clinical practice. Those modern family contexts that previously – or even today in some circles – might have been considered to have a negative impact on children do not in themselves cause harm to children. Rather, the underlying and sometimes hidden factor, and the link to childhood and later psychopathology, could be the associated early trauma for the child. I aim to weave the thread of this important finding into the following discussion about some of the different forms of non-traditional families today.

The loss of a parent – or being permanently separated from a parent – at a young age is traumatic for children. It can be associated with psychopathology that sometimes persists into adulthood. Research also shows that newborns recognise their own mothers and are emotionally distressed when separated from them. Post-natal emotional support for mothers can have a positive effect on the mother–infant relationship and the quality of attachment, with associated better outcomes for physical health, lowered rates of failure to thrive in infancy and early childhood, fewer chronic and recurrent health problems, and better health and lifestyle practices in adulthood.

Parents have more influence over their children than do most other people they will encounter in their lives. Children inherit genes from their parents; they also learn how to function in the world based on who their parents are and how their parents think, feel and behave. Some psychological disturbances and psychiatric disorders have been linked to problems with early parenting. In their article about parenting and child mental health, UK-based researchers Rachael Ryan, Christine O’Farrelly and Paul Ramchandani noted that parenting is considered a key risk factor in the development of early psychopathology. Low levels of sensitive parenting and greater use of harsh discipline have been linked to the development of behavioural problems. Initiatives that aim to improve parenting early on, when the child's brain and biological systems that underlie mental health are rapidly taking shape, appear to have a better outcome.

Leading US psychologists Ann Masten and Dante Cicchetti examined the developmental cascades in which there have been shown to be cumulative or progressive effects across levels and areas of human development. The functioning in one domain, level or system influences another system or level of function over time to shape the course of development. Involving the parents can help in the process of making constructive changes in many of these areas of development. Intervention with families at risk should involve the parents, who can then be guided towards more sensitive and constructive ways to help their children through the complicated process of growing up.

Parent therapy and guidance

Parents often ask their child's psychotherapist what has caused the child's emotional and behavioural problems. Many of them feel responsible and are willing to shift their attitude and behaviour in ways that will help their children emotionally. The parents create and sustain the child's growing environment. They are the soil in the ground by which the children are nourished as they grow towards independence. Child therapists need to be aware of the kind of environment that parents are creating for their children, and they should guide the parents towards improving that environment where necessary.

Many of the children I see in my consulting rooms do not have abusive parents and they are not experiencing great hardship. They are not suffering due to poverty, hunger or highly dysfunctional dynamics in the family. Their parents generally do not suffer from serious psychopathology – indeed, they are often highly dedicated to their parenting role and involved in their children's lives. But I have noticed a common theme about the lifestyle of these children.

There is a lot of indoor time and much of it is spent in front of a screen. The lifestyle is generally sedentary and involves relatively little physicality. Adventures away from the home and away from the parents are rare, especially if they involve any risk. Time outdoors is limited, and when it happens it is carefully regulated. Crime and the obvious dangers of being outside on the streets account in part for this lifestyle. But it appears that indoors in front of screens is where the children mostly want to be. The Covid-19 pandemic has exacerbated this, and lockdown and quarantine measures have enforced it to some extent. There has been a necessary but concerning retreat behind walls into safety.

David Frye's book, Walls: A History of Civilisation in Blood and Brick, is a useful reminder about the purposes and the unexpected consequences of building walls. Frye noted that walls might indeed provide security for the frightened, educated people inside them. However, they are doomed to fail, and the personal costs of building walls to protect against the dangerous barbarians outside include the loss of much-needed freedom and an ever-weakening mind and body, all of which seem to spiral into further fears about safety. It appears that, with regards to modern children, walls are often necessary but problematic. They can sometimes protect children from threats that include the spread of disease (Covid-19), criminals, child molesters and the harmful rays of the sun. But today's children seem to live in cages of fear, and the outside world, with all of its risks, is viewed as dangerous.

Most parents that I talk to are concerned about this sedentary, indoor, digital lifestyle in which their children are trapped. They are faced with constant battles to get their children off their screens and into nature.

In the Introduction of this book, I refer to Steven Pinker's argument that today's children are better off than they used to be. This may hold true as a generalised trend, but not all environments are child friendly or safe. Some children today are severely, deeply and repeatedly traumatised. The impact of traumatic stress can last well beyond childhood, leading to possible learning problems, increased use of health and mental health services, increased involvement with the child welfare and juvenile justice systems, and long-term mental and physical health problems (including diabetes and heart disease). Childhood trauma is a risk factor for nearly all behavioural health and substance-use disorders.

The question really is, Which children today, born to which parents, living in what areas and under what particular circumstances, are better off? Adversity in childhood places a child at greater risk for psychopathology. According to two leading South African researchers and psychologists, Xanthe Hunt and Mark Tomlinson, children living in contexts marked by adversity are more likely to have negative developmental outcomes. These outcomes include internalising and externalising behaviours, mental health disorders, violence perpetration, delayed cognitive development, peer problems and compromised physical development. The web page of the Substance Abuse and Mental Health Services Administration (SAMHA), part of the US Department of Health and Human Services, states that more than two-thirds of children reported at least one traumatic event by age 16. SAMHA estimates that one in four high school students in the US has been in at least one physical fight, one in five high school students has been bullied at school and one in six has experienced cyberbullying. In addition, 19% of injured and 12% of physically ill youth have post-traumatic stress disorder (PTSD), and more than half of US families have been affected by some type of disaster. In 2015 the national average of child abuse and neglect victims in the US was 9.2 victims per 1 000 children.

In South Africa and various other places around the world, the picture is even more disturbing. The Optimus Foundation study of sexual victimisation of children in South Africa found that 35.4% of adolescents have experienced some form of sexual abuse at some point in their lives.

The classification of behaviour, emotions and patterns of relating to others into mental disorders is a hotly debated issue. Not everyone believes in it, especially when it extends to children. Any psychiatric diagnosis is a human construct, subject to academic, clinical and public scrutiny. But to be fair, psychiatric diagnoses are constantly being revised and adjusted according to context and an ever-changing world. The International Statistical Classification of Diseases and Related Health Problems (ICD) is a global World Health Organization (WHO) initiative that classifies all health information, including mental health, for clinical and research purposes. The ICD is currently in its tenth revision (ICD-10) and it includes a section covering mental and behavioural disorders. A transition is under way towards the use of the ICD-11, to which neurodevelopmental disorders have been added.

Dan Stein, a Cape Town–based psychiatrist, and 16 international colleagues have published a recent update of the section on mental, behavioural and neurodevelopmental disorders in the ICD-11. The authors discuss the important changes, criticisms and controversies in the updated classification. They highlight its global applicability and clinical utility, but they also note the debates among clinicians and health advocates in the scientific literature and the controversies reported in the lay media. Stein and his colleagues ask whether classification systems such as ICD strengthen mental health practice and research. They point out that the medicalisation of problems of daily life has been questioned, and that there have been concerns that the classifications are not sufficiently grounded in neuroscience. On the other hand, they acknowledge the undoubted value in making a diagnosis for best outcomes in treatment, research and policymaking.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) offers a description of how mental disorders are expressed and can be recognised by trained clinicians. This publication can be a highly useful tool in the process of making an accurate psychiatric diagnosis and formulating a constructive and therapeutic management plan for adults and for children. The original version of what is now the DSM-5 was published in 1844 as a statistical classification of institutionalised mental patients.

Some children as young as two years old can navigate their way around mobile phones, laptops and other electronic devices. They will often ask for their parents’ phones so that they can play simple games or scroll through photographs or other images while their parents are having uninteresting conversations with other adults. There is a mixed response among parents, educators and therapists to children's use of digital devices and the internet. Some people reject and even demonise children's use of technology. Others idealise the place of digital devices in children's lives. Most people fall somewhere between the two polarities – trying to achieve the delicate balance of using technology in positive ways while being aware of its many pitfalls with regards to children and adolescents. Some reflection on and examination of the complexities can help in ascertaining the values and the risks. The solution lies in balance and moderation rather than in extremes.

Children and adolescents have moved online – for better or worse

For older children and adolescents who have had access to it during the Covid-19 pandemic, online learning has saved their education. A reliable internet connection has been a vital part of continuing with life during the pandemic. Children and teenagers privileged enough to have electronic devices in working order with access to data have been able to attend school online, learn, complete and submit assignments, and connect with friends. The Covid-19 crisis has adjusted the way that some people previously viewed screens and the internet's real value has become more acknowledged.

But even outside of the pandemic, some twenty-first-century children who find themselves bored and frustrated with their particular school experience can and do use the internet to extend themselves academically. If they feel dissatisfied with their teachers, they look for ‘better’ ones online. Children today think and learn differently, partly because of modern technology. The internet and smartphones have brought with them a different way of being and a different way of engaging with knowledge. Deep-thinking children who love learning have a prime choice of teachers, mentors and parent substitutes on the internet.

Children in Mind is the book I would like to have read when I was just starting my career as a clinical psychologist specialising in child mental health. The primary focus of this book is modern, up-to-date clinical child psychology in relationship to the context in which today's children are being raised. Many people ask the question, Are children today better or worse off than children in previous generations? The multitude of factors associated with child development and mental health means that the answer is much too complicated for a single, simplified response. Childhood is certainly not what it used to be, and distressed, unhappy children need their psychologists, therapists and educators to be thinking about the current, lived experience of being a child in this new and constantly changing world.

A child's developing mind is deeply influenced by the environment in which he or she is being raised. This context is partly made up of the home, parents, family, peer group and school. The wider context includes the child's community, race and physical location, all of which have their socio-economic, political and historical complexities. Child psychology cannot be isolated from any of these factors. I have written this book from my own perspective as a clinical psychologist trained in South Africa. My clinical experience is with South African children, across a wide range of socio-economic and racial diversity. So there is inevitably some focus on the South African context in this book and it features in certain chapters more than others. However, Children in Mind is not limited to the South African context. It is about all children everywhere and it refers to research from around the world, including from Asia, Europe, the US, Australia, the UK and Africa. My perspective reflects the current worldwide movement towards global mental health. This movement recognises that mental health is a global challenge requiring urgent intervention, with an emphasis on correcting the inequity in health-care provision across deep socio-economic divides.

Whether as educators, psychologists, therapists, medical professionals or childcare workers, people who work with children are typically very interested in the mind of a child.

When the Covid-19 pandemic first began, it was difficult to know what kind of impact it was going to have on today's children. Most child psychotherapists were as shocked and unprepared as everyone else for the ways in which the world changed. Gradually the effects of the pandemic on children are becoming more apparent. I and most of the child psychotherapists in my network have had a dramatic, unprecedented increase in the number of referrals of children to our practices. These referrals are for child mental distress of varying kinds, but the general consensus is that children are suffering as a result of Covid-19 and its associated factors, including lockdown. As noted in previous chapters, children often are not able to express verbally what is causing their distress, and they use their defences in ways that can distract (themselves and their parents) from conscious awareness of their suffering.

At the time of writing this chapter, vaccination programmes – with their promise of hope – are at various stages of rollout in South Africa and globally. The battle against Covid-19 continues and too many people are still dying. People are moving in and out of lockdown, businesses are failing, poverty and unemployment are escalating and mental health problems continue to emerge. Although the pandemic has made its mark on children around the world, the impact on their mental health is highly variable. The child's context, home circumstances, age and school environment all influence her particular experience of the pandemic. More importantly, family dynamics, relationships within the family and the atmosphere inside her own locked-down home play a vital role. The pandemic has highlighted and deepened the divide between wealth and poverty, with lower-income families taking a substantially harder knock. And yet, much of the child's experience of the pandemic depends on how her parents have been affected by and managed the crisis.

Parents set the tone for the child's experience of the pandemic

The pandemic has exacerbated the severe, already existing socio-economic problems that affect the mental health of many children and their families, within South Africa and beyond its borders. This in itself is one of the most serious consequences of the pandemic on child mental health.

As the nature-versus-nurture debate rages on, recent research has opened up news ways of thinking about it. The debate has become far more interesting and complex. Emerging from current research is the finding that mental functioning and human behaviour are neither just nature nor just nurture alone. They are influenced by a complex interaction between both nature and nurture. Genetics (nature) is linked to mental health, personality, behaviour, mood and relationships in ways that interact with the growing-up environment (nurture). In order to understand this complexity, it is important first to grasp some basics about genetics.

The study of the gene is called genetics, which is derived from the Greek word genesis. This can be loosely translated as ‘origin’. Genetics is about the inheritance of traits. These traits are not limited to characteristics such as eye colour and predisposition to certain physical illnesses. They extend to human behaviour and mental conditions as well. Epigenetics refers to the way in which the intracellular or extracellular environment may switch gene transcription on or off. Life circumstances – including home and school life, relationships with caregivers and others, as well as anything important that happens in a child's world – can cause genes to become either silenced or expressed over time. Epidemiological studies suggest that genetics, or heritability, accounts for 40–50% of depressive disorders and 30–40% of anxiety disorders.

Psychologists are sometimes critical of the role genetics is said to play in mental health. There are important reasons for this scepticism. An attitude of ‘it's all in the genes’ can be reductionistic, disregarding the value and complexity of psychological theory and practice. Yet, although people and animals are quite different in many ways, it's important to note that some animals are bred precisely for purposes related to specific behaviour and temperament. The vital role of genetics accounts for why certain dogs are bred for human guidance and other kinds of dogs are bred to fight. Understanding genetics in relation to mental health is not a replacement for psychological theory and psychotherapy. It does, however, enhance and enrich the understanding of human behaviour, psychopathology and personality.

Things are changing so fast that today's world will soon be yesterday's world and this book will need revision. A review of some of the literature about whether childhood behavioural and emotional problems are worse today than what they were a few decades ago reveals some contradictory and confusing findings. It depends which children are being examined, under what contexts and where. Some researchers and authors are sure that children are more distressed these days. As is true for all matters related to mental health, the issues are complicated and cannot be oversimplified. Research does seem to show that certain childhood mental disorders are diagnosed more frequently today than before. Autism spectrum disorder is one example. Conduct disorder under certain circumstances also seems to be on the rise.

Some research suggests that today's children are unhappier and more anxious than they used to be. There are theories and assumptions about why this could be so, some based on more evidence than others. Hypothesised reasons – based on some convincing research – for increased distress in children include excessive use of screens, social media and the internet, as well as extreme pressure and stress with regards to achievement and success. Requiring more research is the popular opinion that children are less happy nowadays because they are sometimes alienated from nature and the outdoors and their lives are less free, physical and playful. It is widely accepted that being exposed to adversity such as toxic stress in early life, ongoing traumatic experiences, dysfunctional family relationships, parents with mental disorders, physical and sexual abuse all do have an impact on the mental health of children.

Modern families take all kinds of different forms and this does not necessarily have a negative impact on children. The early trauma and losses that might be associated with these circumstances are probably more likely to bring about a range of emotional and behavioural disturbances. Divorce can be highly traumatic for couples and for their children. But the effects on children are not insurmountable. Divorced parents can play a major role in mitigating the negative effects of their separation by working together as parents in a cooperative and non-conflictual way.

If I were just starting out now in my career as a clinical psychologist, I would be confused about why my teachers in the field hold such contrasting views about mental health and psychopathology. The same confusion is sometimes experienced by parents seeking help for their troubled children. Different doctors and psychotherapists, books and websites will give them contradictory answers to their questions about their children. Perhaps parents seek out what they believe in and what feels most closely in line with their own world views. If I were them, I would want some consensus among the mental health professionals, but at the very least I would expect some tolerance between professional disciples of different theoretical frameworks.

Clinical child psychology – research, theory and practice – involves a confusing mix of conflicting voices of authority and expertise. Clinicians, academics and researchers often locate themselves squarely and with much loyalty within their chosen theoretical frameworks, and they guard their territory fiercely. Advocates of any particular chosen framework in child psychotherapy, for example, are often fully convinced that their way of working with children is the right way. Attempts to challenge this using research or knowledge about a different paradigm often only convinces the already converted. In a literature search you will likely find evidence to support whatever you believe in, as well as evidence that argues against it.

A Google search for cognitive behavioural therapy yields 45 900 000 results, and one for psychoanalytic psychotherapy gives 8 220 000 results. There are other legitimate forms of psychotherapy as well. Those clinicians who are trained and skilled in various therapeutic models are entitled to practise their profession without being harshly judged, as long as they are practising ethically, in their field of expertise, within their scope of practice, and with appropriate supervision until such time as they are experienced enough to practise competently on their own. Continuing professional development (CPD) is an important part of being a clinician, as is being registered with the appropriate professional board so that the clinician is accountable for the work he is doing.

The new field of global mental health aims at addressing the imbalance, inequity and treatment gap in mental health around the world. The study of global mental health emerges against the backdrop of major disparities between rich and poor countries in the provision of care and respect for human rights of people living with mental disorders. Low- and middle-income countries receive less than 20% of the world's share of mental health resources.

South African children are growing up in an unequal society. This is but one example of the reality that wherever in the world inequality exists, the poor face great injustice. The disparity in different socio-economic contexts often means different parenting approaches, different access to resources such as the internet and mobile phones, differences in the quality of medical care and education, as well as differences in opportunities for a range of experiences and skills. Both human immunodeficiency virus (HIV) and foetal alcohol syndrome (FAS) can be more common in lower socio-economic contexts, and many of today's children are the victims of these public health catastrophes. Research published in 2005 on one particular rural district in the Western Cape (South Africa) revealed an extremely high rate – approximately 7% – of FAS in children from that community. This condition is associated with poor growth and development, congenital facial and limb anomalies, and lower intellectual functioning. Global prevalence of HIV is high. Research published in 2013 found that India has among the highest number of AIDS orphans in the world today – estimated at two million. Children diagnosed with HIV have been found to be at higher risk for psychiatric disorders and behavioural problems, and they are faced with significant social and psychological stress.

Xanthe Hunt and Mark Tomlinson researched the effects on children whose early environments are characterised by lower socio-economic conditions. They noted that increases in early-life stressors are common under these conditions and are related to deficiencies in language skills, memory abilities and certain neurological deficits. These in turn impact on other areas of functioning as the child grows into the next developmental stage.

Hunt and Tomlinson described the developmental cascade model, in which early functioning in one domain of behaviour or emotional functioning spills over to influence functioning in other domains.