Emotions & Behavioural Problems

Behaviour Emotions & behavioural problems 15% of UK children have mild emotional / behavioural problems 7-10% have moderate 2% have severe 2-5% of all UK children are seen by GP with emotional / behavioural problems as the main complaint (see below for breakdown) Preschool (<5) Waking /crying at night 15% Over activity 13% Difficulty settling at night 12% Refusing food 12% Mid-childhood (6-12) Persistent tearful / unhappy mood 12% Bedtime behavioural rituals 8% Night terrors / sleep disturbance 6% Bedwetting 5% Inattentive over-activity 5% Faecal Soiling 1% Adolescence (13-18) Appreciable misery 45% Social sensitivity 30% Evident anxiety 25% Suicidal ideas 7% Predisposing factors include Child – genetics, temperament, illness, learning difficulties, language problems, abuse, lack of secure attachment Family – parent discord, parental health / mental health problems, neglect, crime, economic circumstances Environment – overcrowding, homelessness, discrimination, refugee status Life events – parental separation, acute illness, bereavement, experiencing / witnessing sudden & extreme trauma School – bullying, victimisation, inappropriate curriculum Protective Factors Child – easy temperament, at least average intelligence, positive attitude, sense of humour, sense of self-mastery Family – high warmth, low criticism, appropriate boundaries & discipline, absences of parental discord, secure attachment to at least one parent Social environment – affectionate ties with parental substitutes (e.g. child minder, teacher), external support system, positive school experience, opportunities for meaningful social roles & experiences Learning Problems 10-15% of all children will have some form of learning problem Dyspraxia (Clumsiness) Fine motor developmental delay à poor handwriting Gross motor à difficulty with sports etc Assoc with social & academic problems Rx - co-ordination training can help Reading Retardation Multiple factors (vision, teaching, reading delay) B>G, often +ve FH Support to ensure rest of learning & development is not affected Speech & Language Multiple factors Hearing impairment Intellect Grammar Mouth/tongue problems (incoordination) Psychosocial skills - e.g. infantile autism / Asperger’s syndrome Nocturnal Enuresis Majority dry by 3y 10% enuresis at 5 yrs <5% at 10 yrs 1-2% have organic problem à check DM, DI, UTI Often emotional problem 70% if FH Rx: no fluids after 6pm, void b4 bed, star charts, desmopressin (ADH), alarms Encopresis (Faecal Soiling) Passage of formed faeces in unacceptable places Usually clean by 2y, abnormal by 4y B>G Multiple factors - inadequate training, irregular bowel habit, constipation à overflow incontinence Rx Toilet training @ regular intervals with rewards if stool passed Good diet & exercise Empty bowel – continue active treatment for 3-6 months after clean Tics Sudden repetitive movements of no purpose Onset 5-8 yrs B>G, 25% have FH Worsen if nervous, excited or relaxed Some have evidence of brain damage / delayed maturation 50% disappear spontaneously by adulthood (drawing attention will worsen them) Can progress to Tourette’s Tourette’s 2+ motor tics + 1+ vocal tic for over 1 year EEG is non-specific Learning Difficulties – could be due to hearing / vision problems etc Learning disability Mild (IQ 50-70) 15% have mild-mod Moderate (IQ 35-50) 70% = mod - severe Severe (IQ 20-35) NB: 70 = 2s.d. below mean BUT also need to take into account development in children If developmental functioning at ½ physical age = moderate, if 1/3 physical age = severe Causes Largest cause in children is genetic (Down / Fragile X) 2nd largest = cerebral malformations Also hypoxia / toxins / social or economic or psychological deprivation / hypothyroid / lead poisoning About ½ of severe cases will find a cause, about 20% in mild Clinical evaluation Most commonly present with developmental delay Assess background – alcohol / smoking / economic risk factors will interact with genetic factors Elicit parental concerns – will raise 80% of patients if done systematically (eating/sleep /speech/movement etc) = can be as effective in GP as stacking bricks etc Assess for dysmorphic features, growth, general health History of siblings esp early / unexpected deaths which may be due to metabolic conditions Key concern points “Limit Ages” Not sitting by 10m Not walking by 18m No clear word by 18m-2y Not putting words together by 2 ½ y Still mouthing by 1y-18m Test for causes – esp if reversible / treatable Anticipate future problems (physical, behavioural, mental health etc) Describe child’s needs for education/ carers / financial support ADHD Autism Triad of Inattentive, hyperactive & impulsive Classified by ICD10 Give Connors Questionnaire to parents, teachers and any other adults who interact with the child Must have been observed with symptoms for 6 months. 1-5% of population, B>G Co-morbidities: autism, Tourette’s, dyslexia, OCD, conduct disorders. Rx: Check vision & hearing. Behavioural therapy, Ritalin (methylphenidate), atomoxetine ΔΔ bright but bored, family issues, copying siblings, deaf, learning disability with poor support. 20-40/million Boy 3x > g, strong genetic link More prevalent in higher social classes Onset at < 30 months Usually start to present at 2-3 years (decreased eye contact, decreased stranger anxiety, lack of symbolic play) Triad of Little non-verbal communication Social function disordered relationships Imagination deficit - ritualistic behaviour, repetitive movement, 40% develop epilepsy during adolescence 70% also have learning disability 50% of autistic children will not be speaking at school entry age Rx: intensive communication skills training, provide regularity in everyday life Asperger’s NORMAL cognitive function & language development Decreased understanding of emotions Odd behaviour Marked social impairment Behavioural Problems Feeding - Difficult baby or insecure parent, can vomit / refuse / FTT Sleep – 85% if 6m sleep through, 10% of 1yrs wake regularly over night Dysomnia – problems settling, night waking Parasomnias –nightmares, night terrors, sleep walking Hypersomnias - narcolepsy Rx: regular routine & not responding to crying Breath holding – Very common Start at 6m, peak at 2y, stop by 5y Usually follow noxious injury Shrill cry à forced expiration & apnoea Can à cyanosis & loss of conscious with tonic clonic jerks & opistotonus NOT to be confused with seizures No treatment required Rhythmic behaviour Head rocking/banging, thumb sucking, masturbation More common if child is bored, anxious, excited or tired Recurrent Abdo-pain Occasionally organic, can be cry for help Ix usually –ve School Refusal Refusal due to fear / depression = neurotic / emotional disorder Assoc with social phobia & separation anxiety G=B, can be from stable background and in children with good school results High levels of emotional stress Location of child is known during the day Truancy Tend to be large families with poor supervision and open aggression Children believe discipline is unfair Rare in 1o School Parents often initially unaware as not at home during day Oppositional defiant disorder Under 10yrs, persistent provocative / disobedience. 3-4% of pre-school children Strong chance of progressing to conduct disorder. Rx. behaviour Conduct Disorders 3-5% of population, b>g. Repetitive & persistent dissocial / unacceptable aggression, cruelty, antisocial behaviour Worsens with age Linked with TV/media NB – cannot diagnose if underlying psychiatric problems. More common in dysfunctional families, local crime, unemployment etc Emotional Disorders Anxiety states Vary with ages (strangers, animals, dark, social embarrassment) Normal phobias last a few weeks & fade spontaneously Pathological phobias affect day-to-day life Bulimia Nervosa Near normal weight Recurrent binge eating Fear of not being able to stop eating during binge Self induced vomiting / laxative use 2+ binges per week for a minimum of 3 months Self evaluation over concerned with body shape No social class preference Can have menstrual disturbance Anorexia Nervosa >20% expected weight is lost, periods stop 90% F. Incidence of 1/1000 More common in higher social classes 25% are under 13 years old Dx: body image distortion, deliberate restriction / purging. Can have bouts of binging Sx: dental erosions, low BP, low temp, electrolyte imbalance, anaemia, ECG changes. Assoc with hypogonadotrophic hypogonadism Ix: low K+ due to vomiting / laxatives Rx: enforce feed by NG, involve psychologist Depression Requires level of development to understand time (hopeless future) and concept of self (worthless) – usually around 7-9 yrs Misery, hopelessness, usefulness, poor concentration, altered appetite, sleep disruption, psychosomatic aches & pains, indicates high stress Phobias M=F 1% Peak 5-7yrs Worse prognosis if multiple Obsession Obsession = Irresistible urge to repeat a thought of action Compulsion = obsessional behaviour or ritual = Neurotic disorder Begins 5-7yrs, less common than phobias Acute Psychosis Differentials Schizophrenia – clinical diagnosis Mood/bipolar – clinical diagnosis Drug misuse – tox screen Tumour – scan Neuro-degeneration – scan/genetics Wilsons – Serum Cu Porphyria – urine porphobilinogen SSPE – EEG, CSF for measles titres Schizophrenia in childhood 3/10,000 in teens. Rare pre puberty 20% have 1st degree relative = strong FH 1/3 have difficulty with friendships Mean IQ = 80-85 at presentation Hallucinations, delusions & disordered thinking Insidious onset with social withdrawal +ve Sx = delusions, hallucinations (audio>visual), distortion of thought (thought insertion) -ve Sx = withdrawal, decreased motivation, poverty of speech, slowing of thought Rx – rispiridone/olanzapine Prognosis – worse than adults, and worse if delay in treatment Deliberate self harm High risk factors for suicide are young men, highest/lowest social groups, early summer, history of dependences / alcohol / drugs / illness / epilepsy, poor family support, abuse, FH of mental health probs and school work probs Suicide Actual suicide Rare < 12 yrs. Mortality increases with age m>f (more violent methods for boys) 90% have pre-existing mental illness Minor precipitants – school/relationships etc. Attempted suicide g>b Mental illness in 50% Alcohol and drug use common Chronic Fatigue Syndrome Aka post viral fatigue (occasionally evidence of Coxsackie / EBV / Hepatitis) 0.5-1% of 12-16yrs Commonest cause of long term school absence in teens F:M = 3:1 Mean duration 3-4 yrs. Sx Persistent subjective fatigue à rapid exhaustion Myalgia (can be migratory) Headaches Difficulty getting to sleep Poor concentration Irritability Can also have stomach pains & tenderness, eye pain, photophobia & tender cervical lymphadenopathy Depressive symptoms are common Diagnosis Persistent debilitating generalised fatigue with no alternative cause Usually lasts more than 6m (RPCPH criteria has no limit) Fatigue exacerbated by effort Mx MDT approach with graded exercise therapy Sleep hygiene CBT Pain management Treat accompanying mood disorders Home/adapt school education Min Ix FBC, CRP, ESR, UE, Glucose, TFTs, LFTs, Viral serology (EBV), urinalysis