After reading this chapter you should:
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be able to assess, diagnose and manage common emotional and behavioural problems
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know about the effects of physical diseases on behaviour and vice versa
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know and understand the presentation of conduct disorders and antisocial behaviour
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understand the role of Child and Adolescent Mental Health Services (CAMHS)
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be able to assess and diagnose important mental health problems
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be able to identify anxiety disorders, phobias, panic attacks, and obsessive-compulsive disorders
Behaviour is the way in which a person acts or conducts themselves, especially towards others. In general, we behave in certain ways for a reason, often to either gain an advantage or to guard against actions which may have an adverse effect. It is also important to consider any extrinsic factors that may affect an individual child and what the behaviour pattern might indicate about their lifestyle.
Common emotional and behavioural problems
Sleep Problems
It is well recognised that sleep is important in helping the overall quality of life and is thought to help lay down memories and filter what needs to be remembered. Lack of sleep affects concentration and attention and can therefore increase problems with behaviour.
Both settling to sleep and waking in the night are common problems seen throughout childhood. Parasomnias are behaviours that interrupt sleep and include nightmares and night terrors. These activities are most common in children under 5 and decrease in frequency over the following years. Children with neurodevelopmental problems and mental health difficulties are more likely to suffer sleeping difficulties.
The amount of sleep needed changes through childhood and adolescence. Babies will spend more of their time asleep than awake, usually waking for feeds but gradually increasing the periods of alertness between naps.
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2-year-old will have nearly 12 hours sleep at night plus over an hour during the day
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5-year-old needs 11 hours at night on average
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9-year-old will have 10 hours
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14-year-old will have 9 hours
It is normal for children to wake in the night for a few minutes, but those who experience difficulties with self-settling can find it difficult to go back to sleep when this occurs. The phases of sleep include periods of light, deep and REM sleep. Figure 7.1 :
It is also important to consider the typical body clock for children and young people of different ages. Adolescents often do not feel tired until late in the evening and will choose to sleep into the later morning whilst some young children will wake early.
Some medical problems can present with sleeping difficulties.
Obstructive sleep apnoea and sleep disordered breathing will produce loud and excessive snoring in the child along with periods of apnoea. The snoring might wake the child or other family members and so draw the attention of the parents to the problem. A sleep study can help to determine oxygen saturations overnight and determine if the breathing appears disordered; in such situations, a referral to a respiratory physician or ENT surgeon can be helpful. Treatment will usually depend on the cause but can include treatment of comorbidities such as obesity, adenotonsillectomy and even noninvasive ventilation.
Pain can be a recognised cause of interrupted sleep and underlying causes should be sought.
Restless leg syndrome is linked to iron deficiency.
Narcolepsy is a rare neurological condition characterised by excessive daytime somnolence and can be associated with cataplexy (drop attacks on laughing and suddenly fall to sleep). Diagnosis of narcolepsy is made with a multilatency sleep test and possibly a lumbar puncture to look at the level of orexin (a neuropeptide that regulates awakened state) in CSF.
Smith-Klein-Levin syndrome is a genetic neurological disorder and describes a child who falls asleep for prolonged periods. Like narcolepsy, the condition needs careful management by a specialist team.
Up to 30% of healthy children have problems with bedtime or nighttime waking at some point in their childhood and problems are usually related to:
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bedtime resistance or refusal
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delayed sleep onset
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prolonged night awakenings
Important factors in the child that may impact on patterns of sleep include neurodevelopmental disorders and anxiety. There are also environmental factors to consider such as a shared bedroom, parents working long hours, domestic violence or parental mental health problems.
Bedtime resistance or refusal
Children often refuse or resist going to bed and there can be many distractions in the family home which can contribute to this effect. Helping to minimise these and build a good bedtime routine are therefore helpful. A routine with three or four soothing activities is advised and should not involve screens, TV or electronic devices as these can inhibit melatonin production due to the emitted blue light.
Allowing a young child to cry themselves to sleep—controlled crying—can work for some whilst a gradual withdrawal from the room by the carer can help others. Gradual withdrawal is useful for those children who need the parent in the same room to fall to sleep. Older children who are anxious about falling to sleep may benefit from support to address the anxiety.
Delayed sleep onset
This is common in children with neurodevelopmental conditions such as autism spectrum disorder or ADHD. Some children do not feel tired until later in the night and implementing a planned ‘bedtime fading’ has been shown to be beneficial. This involves moving the bedtime to a time the child would naturally fall asleep and then bring it forwards by 15–20 minutes every few nights. For older children, the advice of using the bedroom as a place to sleep, rather than to relax, chat to friends and play games can also help.
Nightmares and night terrors
Nightmares and night terrors are common in children between the ages of 3 and 9 years. A nightmare is a vivid dream, and the child wakes and seeks reassurance from a caregiver. That is in contrast to a night terror, where the parent finds the child in a distressed, agitated state and yet may still appear to be asleep. Reassurance by the caregiver is usually the only course of action needed although anticipatory scheduled waking may help children with recurrent night terrors as they often occur at the same time each night.
Delayed sleep-wake cycle disorder
Adolescents and young adults can have a circadian rhythm that lasts more than 24 hours and so leads to a shift in their sleep-wake cycle and can impact on school attendance or other activities.
Relevant pharmacological agents used
Occasionally, when all sleep hygiene strategies have been tried, children with neurodevelopmental conditions or significant anxiety can be given a trial of melatonin. This has been found to be effective in helping reduce sleep latency (time taken to fall asleep) and can increase total duration of sleep by approximately 30 minutes. It should only be used in the short term, although those with neurodevelopmental conditions may need it for much longer. There are no long-term studies looking at its efficacy or safety.
Historically, children with neurodisability have also been prescribed chloral hydrate and sedating antihistamines such as promethazine. These are seen as less favourable options as they can cause adverse ‘hangover’ effects and so increase behavioural problems in the daytime.
Feeding difficulties
Food is an emotive subject and all parents are concerned when their child has difficulties with eating. There can be a number of different reasons for children presenting with feeding problems:
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pain or discomfort related to eating as with gastro-oesophageal reflux or respiratory conditions
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sensory processing difficulties result in certain tastes, textures and smells being overwhelming. This can often result in the child only eating a limited number of foods that they recognise and will accept
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negative feeding experiences (severe choking or reflux) that have led to anxiety about eating
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developmental stage—many toddlers go through a phase of fussy eating and this generally improves with time
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chronic medical conditions (malignancy, iron deficiency) may make eating unpleasant
Management includes:
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ensuring that the child sits at a table to eat in an appropriate seat and is offered the same meal as the rest of the family
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ensuring that the child’s growth follows the expected centile and referring to a dietician if needed
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ensuring that reflux medication is optimised
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encouraging the child to play with food
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offering the same food on many occasions
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referral to a speech and language therapist to help with oral desensitisation
Avoidant and Restrictive Feeding Intake Disorder (ARFID)
ARFID is a recognised feeding disorder and is diagnosed when there is an eating or feeding disturbance such as:
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lack of interest in eating or food
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avoidance of food due to the sensory characteristics of food
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concern about aversive consequences of eating
It can cause significant nutritional deficiency and weight loss such that some children require enteral feeding via an NG or PEG tube. The feeding disturbance is also not explained by a medical condition, lack of available food or concerns about body image.
People with an autism spectrum disorder, sensory processing difficulties and those who have suffered negative feeding experiences such as severe, painful gastro-oesophageal reflux, are all at risk of developing ARFID. The condition is often linked to anxiety, indicating that such children are more at risk of other psychiatric disorders and they do not outgrow the typical ‘picky’ eating phase that occurs during early childhood.
ARFID is usually managed by a multidisciplinary team consisting of a combination of a paediatrician, speech and language therapist, occupational therapist, dietician and psychologist with advice given about trying to encourage feeding and improving a child’s repertoire of foods.
Pica
The history of a child seeking out and eating soil, paint, soap or other items without any nutritional value will raise concerns in parents and carers and suggest a diagnosis of pica. Such activity can be seen in children with intellectual disability but can also be seen in elemental deficiency such as iron or zinc. Further assessment and possible investigations will usually be needed.
Behavioural manifestations in physical disease
Children show many behavioural manifestations of physical disease and they can often feel anxious when they are unwell. Anxiety can manifest as physical symptoms such as tachycardia, feeling faint, ‘butterflies in the stomach’, but it can also manifest as aggressive or violent behaviour.
It is also important to remember that diseases or treatment that affects the brain can cause problems with behaviour and examples include:
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children with brain tumours can present with personality changes and may appear as angry, aggressive or uncooperative.
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thyroid disorders can mimic psychiatric conditions; for example, those with hypothyroidism may present as depressed and lethargic whilst those with hyperthyroidism could be agitated and hyperactive.
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anti-epileptic drugs such as sodium valproate and levetiracetam can cause behavioural side effects.
Impact of chronic disease
There is a massive and complex interplay between physical and mental health and this is certainly the case when a child and family are facing the implications of living with a lifelong condition. Psychological support for children with any chronic illness is very important in helping to manage the situation and will improve their outcome.
A 14-year-old girl was recently diagnosed with type 1 diabetes and was under the care of the Diabetic Team at the local hospital. She had been progressing well at school and was described as ‘popular’ with a close group of friends. Following the diagnosis, she became withdrawn and prone to outburst of temper.
A meeting with a team psychologist was able to identify the issues of concern to the girl and these included:
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initial response to diagnosis by child and family was one of upset and distress
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recognition and realisation that this was a disease that she would have for the rest of her life and this led to a grief reaction for the life she may not have
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the need for daily injections, treatment and pumps had a physical and psychological impact on her
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she described feelings of rebelliousness, unfairness, difference to peers and asking ‘why me?’, ‘I didn’t ask for this’.
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she expressed feelings of denial at becoming unwell suggesting ‘it won’t happen to me’
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the need to take responsibility for her condition rather than it resting with her parents led to family disputes
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the resentment that the illness occurred at the time she was developing her own independence
Once these issues were identified and discussed, it was possible to introduce measures which may help.
Somatic symptom disorders
Disorders where there are somatic symptoms include:
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somatic symptom disorder
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illness anxiety disorder
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conversion disorder (functional neurological symptom disorder)
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fabricated or induced illness by carers
In these conditions medical pathology is absent or, if present, the symptoms are unexplained or over-exaggerated and cause distress and impairment. These disorders are uncommon but they can cause significant demand on healthcare resources.
Somatic symptom disorder
Young people present with somatic symptoms that consistently disrupt daily life and spend a significant amount of time thinking about these symptoms or health concerns.
Illness anxiety disorder
The individual does not have somatic symptoms or, if present, are only mild in intensity, but the young person has a high level of anxiety about health and undertakes excessive health-related behaviours such as repeated body checks. They are preoccupied with the notion that they will develop a serious illness.
The main difference between a somatic symptom disorder and illness anxiety disorder is that the distress that occurs in an illness anxiety disorder is not from the physical symptoms but instead from the anxiety around illness itself.
Conversion disorder (functional neurological symptom disorder)
This describes presentations in children and young people where there are symptoms of altered voluntary motor or sensory function which are unexplained by recognised neurological or medical conditions. Physical examination and investigations are normal. The symptoms cause clinically significant distress or impairment in important areas of everyday life and comorbidities with anxiety and depression are common. Young people affected by this condition are often highly functioning individuals and the psychological trigger may be subconscious. Treatment is focussed on reassurance, support and explanation and it is important for the patient to understand that the symptoms they are experiencing are real.
Antisocial behaviour and conduct disorder
Aggressive and defiant behaviours are part of normal childhood and growing up and, in particular, teenagers are often defiant as they question boundaries set by their parents and find their own ideas developing.
Conduct disorders
These are characterised by:
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repetitive and persistent patterns of antisocial, aggressive or defiant behaviour
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behaviour that amounts to significant violations to everyday social expectations
Such conduct problems are relatively common and the number of children and young people demonstrating problems with antisocial behaviour increases into adolescence.
Conduct disorders are seen more commonly in those who are looked after, have been abused, are on a child protection plan or have ADHD.
Characteristic features of conduct disorders include:
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aggression to people and animals—lies, initiates fights, cruelty to others and to animals
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deliberate destruction of property—destroys the property of others, starts fires
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deceitfulness or theft—steals, burglary, shoplifting
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serious violations of the rules—truanting, runs away from home, bullies others
These behaviours are not simply ‘one-offs’ but must have been occurring consistently for at least 6 months.
Risk factors for developing a conduct disorder include:
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local community (‘difficult’ neighbourhoods)
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influence from friends
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physical abuse
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witness to domestic violence
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attachment difficulties
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intellectual disability and learning difficulties
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family disadvantage
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negative, harsh, inconsistent parenting style
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