Behavioural and emotional problems (Paediatrics).

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  Investigations

  A complete developmental history and examination is important: not just social/emotional, but also speech, hearing, or cognitive problems, which can also cause behavioural problems.

  Learn the ABC of the problems:

  • Antecedents
  • Behaviour
  • Consequence

• Separation anxiety

  • Anxiety about separation from main caregiver.
  • Part of normal development from 6-8 months.
  • By 2 years it usually reduces as they can extend attachment to others, and by school age they can normally tolerate hours away from parents.
  • Its persistence or re-emergence beyond this time may be pathological, and known as separation anxiety disorder.

• Temper tantrums

  Common when kids reach an age where they have to comply with demands.

• School refusal

  Definition

  • Inability to attend school due to overwhelming anxiety, which can be either parental separation anxiety, school phobia, or both.
  • The anxiety is disproportionate i.e. not explained by rational fear of bullying or learning problems.

  Signs and symptoms

  • Anxiety
  • Hyperventilation
  • May somatise as nausea or headache, which clears up at weekends.

• Attention deficit hyperactivity disorder (ADHD)

  Epidemiology

  • First signs can often be seen before school age, though some not diagnosed until adulthood.
  • Commoner in males, but likely underdiagnosed in females.
  • Genetic predisposition.

  Signs and symptoms

  • ↓Concentration and disorganised.
  • Overactive, disinhibited, and impulsive.
  • Temper tantrums.
  • School problems, which may lead to ↓self-esteem
  • Diagnosis requires presence of symptoms in ≥2 settings e.g. school, home, work.

  Management

  1st line is education and support:

  • Psychoeducation for patient and family, including explaining what behaviours are due to ADHD and what is just normal.
  • Environmental modifications e.g. using headphones, more frequent breaks.

  2nd line is medical therapy:

  • 1st line is methylphenidate.
  • 2nd line is atomoxetine, dexamfetamine, or lisdexamfetamine.
  • Can affect appetite and growth, HR, and BP, so monitor them.
  • Potential for misuse and diversion.
  • Add CBT if symptoms persist despite medication.

  In adults with ADHD, medication +/or CBT is 1st line.

• Disruptive behaviour

  Disruptive mood dysregulation disorder (DMDD)

  • Angry or irritable mood, which is persistent (as opposed to episodic as in e.g. bipolar, depression).
  • Severe temper outbursts.
  • These feelings and behaviours lead to functional impairment e.g. at home, school, or with friends.

  Oppositional defiant disorder (ODD)

  • Argumentative and defiant behaviour.
  • Spiteful or vindictive.
  • Angry and irritable mood may be present, though less prominent than DMDD.
  • Unlike conduct disorder, do not routinely aggress people, animals, or property.

  Conduct disorder (CD)

  • Antisocial acts, namely behaviours that infringe on the rights of others, including violence.
  • May also involve harm to animals or property, rule-breaking, theft, or deceit.

  Distinctions

  • All involve disruptive behaviour, but DMDD is primarily a mood disorder, while ODD and CD are characterised by their hostility towards others, with CD more severe and with the hostility translated into harmful conduct.
  • Despite these distinctions, these conditions may be co-morbid with each other, as well as other conditions such as ADHD.

• Eating disorders in young people

  • Anorexia nervosa onset peaks at 14 years. It is 10 x commoner in females.
  • Bulimia onset peaks a few years later.

• Self-harm

  Aka nonsuicidal self injury.

  Definition and epidemiology

  • Defined as intentional destruction of own tissue without suicidal intent. Some definitions (e.g. NICE), however, don't specify what the purpose is.
  • Commoner in adolescents (15%) than adults (2%).
  • Arm, hand, and wrist are common sites.
  • 50% due to depression. Also seen in many other conditions, especially borderline personality disorder.
  • Although these acts are non-suicidal, around 50% of self-harmers attempt suicide at some point.

  Symptoms of depression in young people

  • Apathy and boredom (more than anhedonia).
  • Separation anxiety reappears.
  • Educational decline.
  • Social withdrawal.
  • Hypochondria
  • Irritable and antisocial.

  Red flags for suicide risk

  CRISIS:

  • Critical of self.
  • Repulsed or Indifferent/apathetic about life.
  • Suicide doesn't scare them.
  • ISolated from family (or has poor relationship with them).

  Management

  Overview:

  • Understand that self-harm is often a coping strategy for mental distress, and the patients' individual reasons for doing it should be sensitively explored.
  • Particularly important to involve the patient in treatment decisions.
  • Involve family in care if patients agree.

  Acute:

  • Urgent medical referral (e.g. A&E) if there is significant physical harm.
  • Assess suicide risk. CAMHS crisis team if at risk.

  Assessment and advice:

  • For longer-term planning, do a full biopsychosocial assessment of their needs and risks. This includes the risk of repeat self-harm, protective and risk factors, psychiatric co-morbidities, and other risk behaviours such as substance misuse and unsafe sex. Simple risk assessment tools and scales are not recommended.
  • Plan for long-term treatment is agreed with patient and based on both needs and risks. Aims may be to stop self-harm entirely, or reduce the harm that results.
  • Advice for those who repeatedly self-injure: harm minimisation techniques (e.g. safer cutting), self-management of superficial injuries, and alternative coping strategies.
  • Advice for those who repeatedly self-poison: there are no safe levels and poisoning should be avoided at all costs.
  • Provide similar advice and education for family members.

  Long-term treatment:

  • 3-12 sessions of psychological therapy, including CBT, psychodynamic therapy, and/or problem-solving.
  • No specific drug treatments available for self-harm. However, they may exist for psychiatric co-morbidities. Keep in mind the risk of overdose.

• Enuresis

  Definition and epidemiology

  • Enuresis is involuntary urination, and can be nocturnal (bedwetting) or diurnal (daytime wetting).
  • It is common, affecting 10% of 5 year olds regularly, and 30% occasionally. Around 3% of teenagers have regular bedwetting.
  • Primary enuresis: child who has never been dry. Usually a benign developmental delay (normal up to age 5) or part of a global delay such as Down's.
  • Secondary enuresis: new onset in a child who has been dry >6 months. May suggest pathology (e.g. UTI), abuse, or psychological problems.

  History

  • When, how often, and how much. Large volumes early in the night suggest simple bedwetting. Irregular, variable volumes at night suggest overactive bladder. Daytime wetting suggests overactive bladder, UTI, or diabetes.
  • Daytime fluid balance: are they drinking too much or not going enough?
  • Associated symptoms: urgency and dysuria (UTI), thirst and weight loss (diabetes).
  • Soiling may suggest faecal impaction which is causing the enuresis through bladder compression.
  • Is it situational e.g. school?
  • Were they previously dry, and if so, are there any new stressors?

  Investigations

  Check for UTI and diabetes only if:

  • Onset is recent i.e. last few days-weeks.
  • There is daytime wetting.
  • There are other signs or symptoms suggestive of the diseases.

  Management

  Basics:

  • Reassure child and avoid blaming or shaming. Get their ideas, concerns, and expectations.
  • Consider nappies if young, or waterproof bed protection if older.
  • No specific treatment usually needed for nocturnal enuresis if age <5. Older children should be managed as outlined below.

  1st line, behavioural:

  • Encourage behaviour changes with praise and reward systems, not blame and punishment.
  • Avoid excess fluid during the day and especially before bed, but don't fluid restrict. Appropriate amounts are age and gender specific.
  • Void regularly during the day (4-7 times) and before bed. Void if they happen to wake during the night, but regular waking for the purpose of voiding is not recommended.

  2nd line, alarm training:

  • Alarm triggered by wet bed is highly effective.

  3rd line, medical:

  • Desmopressin (ADH) is the 1st line medical treatment. Use if >7 years old (consider if 5-7) and alarm training is ineffective or rapid control needed e.g. sleepover coming up. Withdraw for 1 week every 3 months to check if still needed.
  • Other options: imipramine (TCA), oxybutynin (anticholinergic).

  Daytime wetting >5 years old suggests urinary tract problems and typically requires referral to secondary care.