Behavioural
problems in childrenEarly childhood
Impact of Problems
Areas of impact
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Types of Impact
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Aetiological Factors
Domain
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Type
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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 .....
- introduce intention to change tack
We've spent some time talking about John's infection. I'm also wondering about other types of difficulties ... - normalise behavioural difficulties
.... many young children are difficult to manage at times .... - link to something already said
... you said earlier that he sometimes has tantrums .... - enquire directly
.... do you find John's behaviour difficult to manage?
Observable indicators of behaviour problems
- Parent:
- developmentally inappropriate expectations
- lack of warmth & positive attention
- frequent negative commands
- use of threats to control behaviour
- 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
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How to ignore effectively
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Schoolchildren
Impact of problems
Areas of impact
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Types of impact
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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 ......
- 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 .... - Normalise emotional difficulties
.... Many children worry about things at times .... - Link to something already said
.... You said earlier that Helen sometimes has trouble getting off to sleep .... - Enquire directly
.... Is she a girl who tends to worry about things? .... more so than other children of her age?
Interviewing children
General principles
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Areas of questioning:
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Useful additional questions:
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Management
GP Management of Psychosomatic
Problems
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Parental Management of Psychosomatic Problems
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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
Adolescence
Areas of impact
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Types of Impact
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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 .....
- introduce intention to change tack
We've spent some time talking about your acne. I'm also wondering about other types of difficulties .... - normalise psychological difficulties
Many young people get misdeable from time to time... - link to something already said
... you said earlier that your acne was getting you down .... - enquire generally
.... Do you have any other worries or difficulties? - 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)