Behavioural problems are a common manifestation in children, ranging from normal tantruming in toddlers to significant Conduct Disorder in older children. Behavioural problems are more common in those with other neurodevelopmental and behavioural disorders.
Attention Deficit Hyperactivity Disorder (ADHD) – this diagnosis is covered in the ADHD section.
Oppositional Defiant Disorder (ODD)
- A pattern of negativistic, hostile and defiant behavior lasting at least 6 months, during which 4 or more of the following are present (* only if behaviour occurs more than is normal for a given age and development level):
- Often loses temper
- Often argues with adults
- Often actively defies or refuses to comply with adults’ requests
- Often deliberately annoys people
- Often blames others for his/her mistakes or misbehaviour
- Often angry and resentful/often spiteful or vindictive
- Causes clinically significant impairment in social, academic and/or occupational function
- Not occurring during the course of a mood or psychotic disorder
- Criteria are not met for Conduct Disorder
CD (Conduct Disorder)
- Repetitive and persistent behaviour in which the basic rights of others, societal norms or rules are violated, with three or more in the last 12 months, and one or more in the last 6 months:
- Aggression to people or animals
- Bullies, threatens or intimidates others
- Initiates physical fights
- Has used a weapon that can cause serious harm to others
- Physically cruel to people
- Physically cruel to animals
- Stealing whilst confronting a person e.g. mugging, purse-snatching
- Has forced someone into sexual activity
- Destruction of property
- Deliberately engaged in fire lighting with intention to cause serious damage
- Deliberately destroyed others’ property
- Deceit or theft
- Has broken into someone’s house, car of building
- Often lies to obtains goods/favours or to avoid obligations
- Stealing items of non-trivial value
- Serious violations of rules
- Often stays out at night despite parental prohibitions (beginning before 13 years of age)
- Has run away from home overnight at least twice
- Often truant from school (beginning before 13 years of age)
- Causes clinically significant impairment in social, academic and/or occupational function
- Aggression to people or animals
- Normal children display many features of ADHD and ODD as normal developmental variants in their first few years of life, thus this does not equate to a diagnosis.
- Consider developmental delay, intellectual disability or learning disorders manifesting as behavioural difficulties.
- It is always important to gather information on the child’s behaviour from the school and other services involved.
- Sleep impacts significantly on childhood behaviour, thus tackling any sleep difficulties is paramount to managing behavioural problems.
- Always remember the role of the family model as a contributing/ confounding factor in the presentation of possible behavioural problems.
- It is not legal for schools to ‘expel or suspend a student until paediatric review occurs’, nor is it within the school’s mandate to suggest a pupil is medicated for behavioural control.
It is important to take a stepwise approach to the management of most behavioural problems.
When there are serious behavioural difficulties that represent an immediate physical threat to the child or others, or if the child shows acute psychosis, urgent referral to Infant and Child Mental Health (0-15 years) or Youth Mental Health (15+ years) Service is required (see Mental Health Services index).
Medication
- Medication is not first line management of behavioural difficulties, and is only employed in severe circumstances after other avenues have been explored. Some examples of medications that can be considered are:
- inattentiveness, hyperactivity and impulsivity: stimulants and atomoxetine (see ADHD)
- severe behavioural reactions: clonidine, mood stabilisers and atypical antipsychotics
- anxiety: SSRIs (see Mood disorders)
- sleep disturbance: melatonin, clonidine (see Sleep disturbance)
- On-line resources
- Raising Children Network: excellent resource separated into relevant age groups
- Better Health Channel: many parenting resources, including:
- Parenting programs & support
- School support services
- For schools who are having significant difficulties with a child's behaviour, there are various options for assistance, including both school support services and psychology services.
- Parent support groups
- Pinarc ADHD support group 53291361
- Psychologists/counsellors
- Suitable for when simple behavioural strategies, parenting programs and on-line resources have not been effective
- See Mental Health Services index
- Paediatrician
- generally a non-urgent referral to paediatric outpatient services to i) confirm diagnosis (if any), ii) discuss management strategies and iii) consider appropriateness of medication.
- Information to bring to any appointments:
- recent school reports and any written reports from teachers
- any testing (cognitive, learning, etc)
- behavioural questionnaires (if done)