Behavioural problems in children

• Early childhood
• Schoolchildren
• Adolescence

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Early childhood

Impact of Problems

Areas of impact individual family nursery peer relations

Types of Impact suffering & distress impairment of functioning effect on development

Aetiological Factors

Domain individual family wider environment

Type predisposing precipitating perpetuating

Epidemiology

• 7% of young children in inner London have a moderate or severe behaviour problem and a further 15% have mild problems.
• About three-fifths of three-year-olds with behaviour problems continue to have problems at the age of eight.
• About 90% of young children see a general practitioner over the course of a year.
• Pre-school children with behaviour problems attend primary care more frequently than those without behaviour problems.

Detection and assessment

Consider the following progression …..

1. introduce intention to change tack
   We’ve spent some time talking about John’s infection. I’m also wondering about other types of difficulties …
2. normalise behavioural difficulties
   …. many young children are difficult to manage at times ….
3. link to something already said
   … you said earlier that he sometimes has tantrums ….
4. enquire directly
   …. do you find John’s behaviour difficult to manage?

Observable indicators of behaviour problems

1. Parent:
   • developmentally inappropriate expectations
   • lack of warmth & positive attention
   • frequent negative commands
   • use of threats to control behaviour
2. Child:
   • In attention and overactivity
   • does not comply with parental requests / commands
   • seeks to elicit negative attention

Management

Principles of Effective Parenting

• Have developmentally-appropriate expectations
• Provide calm, structure and routine
• Have a few, explicit and consistent house-rules
• Avoid triggers & trouble-spots (plan ahead)
• Reinforce pro-social behaviour (praise, reward)
• Extinguish anti-social behaviour (ignore)

How to praise effectively Give unqualified praise Praise in front of others Use the child’s name and a warm tone of voice Combine with a smile, eye contact and touch Praise consistently Praise many times an hour (catch the child being good) It may need rehearsal and practice

How to ignore effectively Behave as if you hadn’t noticed (selective blindness) Keep a neutral facial expression Avoid eye contact and comment Turn / move away Ignore consistently Don’t ignore dangerous behaviour Use in the context of positive attention

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Schoolchildren

Impact of problems

Areas of impact individual family school peer relations

Types of impact suffering & distress impairment of functioning effect on development

Epidemiology

• About 1 in 10 schoolchildren have a psychiatric disorder in any one year. The most common disorders are emotional and conduct disorders.
• Aches and pains for which there is on somatic cause and in which psychological factors may play a part, occur in 2-10% of children in general population.
• About two-thirds of schoolchildren see a general practitioner over the course of a year.
• Mental health symptoms are the presenting complaint in about 2-3% of consecutive children attending primary care, but about 20% of consecutive attenders have a psychiatric disorder.
• Schoolchildren who are frequent attenders to general practice have higher rates of psychiatric disorder than other children.

Detection & assessment

Consider the following ……

1. Introduce intention to change tack
   We’ve spent some time talking about Helen’s asthma. I’d was also wondering about other types of difficulties ….
2. Normalise emotional difficulties
   …. Many children worry about things at times ….
3. Link to something already said
   …. You said earlier that Helen sometimes has trouble getting off to sleep ….
4. Enquire directly
   …. Is she a girl who tends to worry about things? …. more so than other children of her age?

Interviewing children

General principles maintain friendly but respectful attitude use simple language & short sentences begin with neutral questions, eg about pets / school

Areas of questioning: worries & sadness concentration & sleep bullying

Useful additional questions: if you had three wishes, what would they be? if you had to go to a desert island, who and what would you take with you?

Management

GP Management of Psychosomatic Problems Investigate and exclude organic disease early on Don’t question the child’s truthfulness (she does feel the pain) Explain carefully that no identifiable organic disease is present Explain the role of psychological factors (eg stress) in amplifying & maintaining physical symptoms Explain that these problems are quite common Convey hope about the likely outcome Communicate your availability and willingness to help

Parental Management of Psychosomatic Problems Both parents should adopt a consistent approach towards the problem Be sympathetic & reassuring but firm Acknowledge but don’t emphasise pain-related behaviour Actively promote non pain-related behaviour Encourage use of simple relaxation exercises & distraction techniques Talk to your child about feelings Maintain school attendance

Indications for Referral to Child Mental Health Services

• Severity of symptomatology (consider nature, frequency & duration)
• Severity of impairment (consider number of areas of life impaired)
• Complexity of problem (consider co-morbidity, multiple stressors, inadequate care)
• Need for specialised assessment
• Need for specialised intervention
• Failure to respond to management within primary care

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Adolescence

Areas of impact individual family school peer relations

Types of Impact suffering & distress impairment of functioning effect on development

Epidemiology

• 15-20% of adolescents have a psychiatric disorder in any one year.
• More than two-thirds of adolescents see a general practitioner over the course of a year.
• Nearly two in five of consecutive adolscents attending primary care in inner London have a psychiatric disorder.
• Mental health symptoms are the presenting complaint in about 2% of attenders.

Detection & assessment

To negotiate seeing adolescent alone, consider the following …..

• It’s been very helpful to talk to you both together …. Now I’d also like to chat to Sarh on her own for a while…
• I often find it helpfl to see young people on their own for a while ….
• It may be easier for Sarah to talk about certain things on her own ….
• Young people often feel more comfortable talking to doctors on their own ….

From physical to psychological

Consider the following …..

1. introduce intention to change tack
   We’ve spent some time talking about your acne. I’m also wondering about other types of difficulties ….
2. normalise psychological difficulties
   Many young people get misdeable from time to time…
3. link to something already said
   … you said earlier that your acne was getting you down ….
4. enquire generally
   …. Do you have any other worries or difficulties?
5. be more specific
   …. do you often get fed up and miserable?
   …. do you find that you feel nervous a lot of the time?
   …. do you worry a lot?
   …. do your worries ever stop you sleeping / concentrating?
   …. do you often worry about your figure and your weight?
   …. Have you been getting into a lot of trouble lately?

Helpful consultations

• Emphasise confidentiality, listen, be respectful
• Make it clear that you take the difficulties seriously
• Connect the symptoms together and name the syndrome
• Link the syndrome to stressors / life-events
• Explain that such problems are not unusual
• Convey hope about the likely outcome
• Communicate your availability and willingness to help
• Discuss links between: feelings, thoughts, somatic symptoms
• Elicit and explore more depressing thoughts / worst fears
• Explore current coping mechanisms and encourage adaptive ones
• Explore and encourage use of external resources (eg support from family and peers)