Behavioural and emotional problems 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.

1. Behavioural and
emotional problems
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2. 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

3. 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.st

4. School refusal

5. 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.

6. Attention deficit hyperactivity
disorder (ADHD)

7. 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.

8. 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.

9. 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.

10. 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.st

11. 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.

12. 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.

13. 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.

14. Distinctions
 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.

15. Self-harm

16. 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.

17. Symptoms of depression in
young people
Apathy and boredom (more than anhedonia).
Separation anxiety reappears.
Educational decline.
Social withdrawal.
Hypochondria
Irritable and antisocial.

18. 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).

19. 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.

20. 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.

21. Assessment and advice:
 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.

22. Enuresis

23. 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.

24. 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?

25. 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.

26. 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

27. 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.

28. 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.

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