Chapter 94: Behavioural and developmental issues and disorders in children

Many behavioural issues in children arise because of (and in the context of) factors such as the child’s temperament, parental schema and child–parent attachment. These factors determine, in the beginning, how the parent–child relationship will evolve, and also strongly affect the psychological development of the child.

Temperament refers to the personality characteristics you are born with—what is innate rather than learned. An awareness of the fact that children are born with characteristics over which parents have no control can be liberating, especially for parents of children with challenging temperaments.

The best-known description of temperament is based on the work of Thomas and Chess from the 1970s¹ (TABLE 94.1). They found that about two-thirds of children can be classified into one of three categories: easy, difficult and slow to warm up. Of these, about 15% were considered easy, 70% slow to warm up and 15% difficult. A child with a difficult temperament will be emotionally labile and have difficulty coping with new experiences. A child with a slow-to-settle temperament will have some difficulty coping with new experiences, but will eventually manage after repeated exposures. A child with an easy temperament will cope easily with new experiences and will have a calm nature.

Easy doesn’t mean good, and difficult doesn’t mean bad. These children may just require more patience and a thoughtful and paced approach to parenting. Further, the characteristics that can make a child ‘difficult’ can be the flipside of other characteristics that lead them to achieve success (if appropriately nurtured and guided). A stubborn child may have good persistence, and a distractible child may be artistic and expressive.

Of course, most children will have a few ‘difficult’ characteristics, but some will have more than others. Raising parents’ awareness of this, getting them to think about the innate characteristics of their child (which may or may not be similar to their siblings or one or both of the biological parents) and to adjust their parenting style accordingly will help them deal more effectively with the challenges of raising their child.

Schema is the view you have of the world based on your own experiences; it is the ‘soup in your head’. Parental schema is how parents view how they should parent, and is often based on how they were brought up themselves. Parental schemas may not match, and this can cause relationship issues. Parental attitudes to issues such as communication, emotion sharing and discipline can fundamentally affect the behaviour and psychological health of a child. Parental schema can also commonly be influenced by cultural factors.

An infant first has to learn how to connect with other minds. A child does this in their first relationship, usually with their mother. This is attachment.

It’s important to note that attachment is an ongoing phenomenon, even into adulthood. Children attach not only to their mother, but to other people from whom they can ‘gather strength’. Children’s attachment to their two parents may differ and can also change over time.

A secure attachment is achieved if a parent responds to a child’s cries promptly, consistently and appropriately. The three main ways in which attachment can go wrong are:

• Carer not responding—this can result in a lack of emotional depth in the child.

• Carer responding inconsistently—this can lead to uncertainty and anxiety in the child.

• Carer responding inappropriately—such as with aggression or anger. This is obviously very damaging, and happens in situations of emotional abuse, particularly with mental health or drug and alcohol issues in the carer. It creates a terrible and unsolvable paradox for children, where the person on whom they are completely reliant to teach them how to relate to the world is also a threat.

Observing how carers, particularly mothers, respond and interact to their child can give the family doctor insight into this relationship. Gently advising and encouraging appropriate responses to the child’s needs can be beneficial, particularly in a mother with poor parenting capabilities and/or difficult circumstances (e.g. very young mothers, socially isolated, postnatal depression, drug using or alcoholic parents, violence in the household). In high-risk situations, further referral to support services or even protective agencies may be required (see CHAPTER 95).

Issues around child behaviour and how to deal with unwanted behaviours commonly arise and are often a source of conflict and angst. It is normal for children, especially toddlers, to have resistant and oppositional behaviour. The word ‘discipline’ comes from the Latin disciplina, which means ‘to teach’. The purpose of disciplining a child is to guide and teach, so they know what is allowed and what is not allowed, what ‘works’ in the world and what will not.

Parents can teach children in a variety of ways. The most effective forms of discipline are actually praise and encouragement—of wanted behaviours. However, when children are doing something that they should not—an unwanted behaviour—they need to learn that this is the case. The challenge for parents is to get this message across to them clearly and effectively.

A simple equation sums up the best way to deliver this message:

unwanted behaviour = unwanted (by your child) outcome

Educating parents to recognise that the thing a child desires most in the world is the attention (this is a survival instinct) and approval of their parents will help them understand how to reinforce desired behaviours, and extinguish unwanted behaviours. That is, pay attention to when the child is behaving, and even praise particularly wanted behaviours, and ignore unwanted behaviours.

Consequences³

Consequences work only with children >3 years of age, and should be used solely in response to a small fraction of a child’s behaviour, regardless of the child’s temperament. If consequences are overused, their effectiveness diminishes and family relationships can be damaged.

There are three types of consequences that work (in decreasing order of usefulness):

• Natural consequences: where there is a natural flow from the misdemeanour to the consequence. For example, if a child refuses to have dinner, he or she goes to bed hungry. Natural consequences have a momentum of their own and, assuming they do not result in harm, can provide many valuable lessons.

• Related consequences: where there is some link between the unwanted behaviour and the result. This is also sometimes called a ‘logical consequence’. For example, if a child makes a mess, he or she must clean it up. Or, if two children are fighting over a toy, the toy gets taken away for a while.

  Related and natural consequences allow a child to link the unwanted behaviour with the consequence.

• Losing a privilege: This can be a very powerful technique as it focuses the child’s attention but is more punitive than natural and related consequences. Also, there is no logical link between behaviour and consequence. Parents should only withdraw a privilege with care as it can cause resentment, and the child should be warned beforehand that he or she is going to lose a particular privilege for a particular unwanted behaviour.

Time-outs⁴ are another response to unwanted behaviours. Time-outs are useful from 2–3 years of age, and can take the heat out of a situation, for both the parent and child. Time-outs should be consistent, enforced promptly and calmly, even with empathy, and short—a good rule of thumb is a minute per year of age.

Responses that don’t work when disciplining children include: screaming, constantly explaining, repeatedly warning, threatening, pleading, arguing, bribing and giving in, as well as smacking.⁵ Most parents who are struggling with behaviour and discipline issues respond with relief when provided with a set of alternative responses for disciplining children, though care needs to be used when raising these issues, as they can be highly emotional and confronting topics for parents.

Maltreatment

GPs should consider maltreatment of the child if there is behaviour change inconsistent with age or development and which is not explained by a problem such as autism or by a stressful situation such as parental separation.

Tantrums⁶

Tantrums are when we lose control of our feelings and behaviour. Everyone, including adults, is capable of tantrums. Tantrums are what we use to deal with an emotionally confronting situation when we have no other option—the emotional response of last resort. They are more common in toddlers (particularly between 18 months and 3 years of age) because they have not learned any or many other emotional responses to challenging situations, such as ignoring, negotiating, reconsidering or reframing a situation. There is a lot of misinformation about tantrums, frequently over-emphasising control rather than guidance. They may be a pointer to autism.

Diverting a child from predictable tantrum triggers, ‘scaffolding’ (giving necessary support) to handle the event (e.g. a 5-minute warning), distraction or active listening in the build-up to a tantrum can be useful strategies to employ.

Once a child is mid-tantrum, any attempts at negotiation will be ineffective. Afterwards, an unemotional and calm response from the parent will tell the child that tantrums don’t work (though, of course, this can be difficult for a stressed parent). Skill-building toddlers in how to handle emotionally challenging situations (i.e. expanding their repertoire beyond tantrums) is best done either before or after (‘What else could you have done?’). Rousing at a child is counter-productive; they are still learning to control their emotions, and this will just increase the risk of them becoming demoralised and losing self-esteem.

Breath-holding attacks⁷

Breath-holding is common (around 5% of children do so at some stage), and occurs between 6 months and 6 years (peak at age 2). While frightening to watch, such attacks are harmless, and no treatment or action is required. There are two types:

• blue spells (more common)—these happen in response to being upset or angry. The child cries loudly then holds his or her breath at the end of expiration

• pale spells—these happen in response to pain or a fright

They can last from 10–60 seconds, and can cause the child to faint or, rarely, fit. They cause no harm, and parents should be reassured. Approaches to discipline should not change because of them. There is no need to blow air or splash water in the child’s face, and the child should be treated as if the breath-holding has not occurred (i.e. no discussion or punishment).

Head banging and rocking⁸

Head banging and rocking, which usually occur before the child goes to sleep, are common. Head banging occurs in up to 30% of normal infants and toddlers, and rocking is even more prevalent. They are more frequent in children with developmental disability and autism, where these behaviours may be more pervasive through the day.

Features

• Usually starts after 8–9 months, and is rare after 2 years of age

• Usually prior to going to sleep

• Child usually not distressed and rarely self-injurious

Management

There is no need to try to stop the behaviour, and attempting to do so is often not successful.

• Reassure parents that it’s a self-limiting behaviour and usually settles by 2 years.

• Avoid reinforcing behaviour by excessive attention or punishment.

• Ignore the behaviour.

• Place the bed or cot in the middle of the room away from a wall (reduces disruption from noise).

• Monitor the condition of the cot, to ensure screws and hinges are not being loosened.

Sibling rivalry

Sibling rivalry is very common and can cause a lot of disruption in the family. A toddler may pinch, prod and even attempt to smother a new baby, so providing the toddler with attention from the mother and encouraging the child to see that it is his or her baby too can ease the jealousy. In school-age children the following tips are useful:⁹

• Be fair.

• Avoid making comparisons between your children.

• Encourage the children to work out their own differences.

• Avoid taking sides in sibling conflicts. Set guidelines on how children can disagree and resolve conflicts.

• Discourage telling tales on each other.

• When it is necessary to punish or reprimand, do it with the child alone in a quiet, private place.

• Use regular family meetings to establish family rules and negotiating conflicts.

Stuttering/stammering

Stuttering (also known as stammering)¹⁰ usually begins at age 2–4 years, as children start to use more words and longer sentences. It can start suddenly or develop slowly. Up to 12% of children will stutter by the age of 4.

Stutters can be repetitions (of a sound, word or phrase), prolongations of a sound (e.g. ‘aaaand’), a block (where no sounds comes out) or combinations of these. There is no known cause, though it can run in families. Stutters are not associated with other disabilities, though they may cause psychological distress for the child. They are not caused by anxiety or stress, but can be more prominent when the child is excited.

A child developing a stutter should see a speech pathologist as soon as possible, as early treatment is more successful. The most common program used in Australia to treat stuttering is the Lidcombe Program, which is often successful and can even sometimes stop the stutter.

Habit cough

This is a common problem usually affecting school-age children and occurs in the absence of underlying disease. It occurs only when the child is awake—not during sleep.

There are two common types of habit cough:

1. A honking-type cough (heard from the waiting room) in teenage girls. There is no dyspnoea or sputum production.

2. A throat-clearing cough commonly seen in boys aged 7–10. This is related to a transient tic disorder.

Habit cough is a diagnosis of exclusion and there should be a careful assessment to exclude other causes such as respiratory disorders or pertussis. Underlying triggers include inter-family problems and bullying or other perceived stress or anxiety. Management includes explanation, reassurance and CBT.

Referral for resistant cases is appropriate.

Other functional respiratory problems:

• hyperventilation

• sighing dyspnoea

• vocal cord dysfunction (see CHAPTER 57)

Sleep disorders in children

See CHAPTER 71.

Bullying^11,12

There are varying figures on how common bullying is, but most suggest more than a quarter of children are significantly bullied at some stage. It is more common in the early school years, but can happen at any age. Bullying differs from conflict, in that there is an imbalance of power between the perpetrator and the victim. It is a deliberate behaviour repeatedly done and intended to harm the victim. It is a power play, constructed on contempt, not anger, and this is what can make it so damaging.

Types of bullying include physical harm, verbal assaults, hidden bullying (e.g. exclusion or spreading rumours) and cyberbullying (now the most common form of bullying). The latter is particularly insidious as it is difficult to detect and follows the victim home and even into their bedroom via social media or phones. Bullying can lead to physical, psychological and social consequences, and in extreme cases depression and even suicide. Despite this, less than half of bullying is reported (with boys reporting less than girls) due to fear of retaliation or not being believed.

Bullies themselves tend to be assertive, impulsive and aggressive, with little empathy for their victims or remorse for their actions. They often come from dysfunctional backgrounds, and their bullying tendency may have been learned from being modelled by parents or peers.

If bullying is raised, the child should be believed, and a history carefully, gently and non-judgmentally extracted. Parents should be encouraged to stay calm, involve other adults in the environment (e.g. teachers at school) and to formally address the issue after educating themselves on the best approach. There are many good resources available for this, such as the National Centre Against Bullying at <www.ncab.org.au>. A vigilant approach to this common and serious problem by GPs and parents should be employed, especially in those particularly vulnerable to bullying, such as children who are shy, lacking in confidence, children with disabilities or who physically or socially stand out in some way (e.g. children with speech disorders). Indicative signs to watch out for include:

• school phobia: sham sickness and other excuses

• being tense, tearful and miserable after school

• reluctance to talk about happenings at school

• poor appetite

• functional symptoms (e.g. habit cough)

• repeated abdominal pains/headache

• unexplained bruises, injuries, torn clothing, damaged books

• lack of a close friend; not bringing peers home

• crying during sleep

• restless sleep with bad dreams

• appearing unhappy or depressed

• unexpected irritability and moods; temper outbursts

Referral to a psychologist should be considered in severe cases, in those that fail to be resolved, or if there are other psychological or family issues. If child abuse is suspected, appropriate action should be taken (see CHAPTER 95).

BEHAVIOURAL AND DEVELOPMENTAL DISORDERS

The family doctor is in an ideal position to recognise and initiate evaluation of the child with a developmental disability, whether it is a physical disability or delay, an intellectual disability or a learning disability. All children with a suspected developmental delay should be promptly evaluated by a paediatrician or a multidisciplinary developmental assessment team, and the family doctor should remain a key player in the long-term management both of the child and the family.

Many developmental problems will be obvious but others are subtle. Several disabilities may evade a diagnosis. Transient developmental delay may be associated with factors such as prematurity, family stress, physical illness and learning opportunities, while persistent delay can be caused by intellectual disability, cerebral palsy, autism and hearing and visual impairment.

Many rare dysmorphic syndromes are becoming more recognised and defined with the rapid advances in genetics, and referral to genetic disorder units will help in getting an appropriate evaluation.

Evaluation

An appropriate history includes a careful look at developmental milestones, social and behavioural issues, and family history (see CHAPTER 9). A new diagnosis of developmental delay of any sort can have a massive impact on family members, especially parents, and the family doctor should keep a watchful eye on how they are coping and reacting to the diagnostic process.

The physical examination includes growth parameters, assessment of all developmental domains, looking for dysmorphic features, testing of hearing and vision, examining for neurocutaneous stigmata (e.g. café-au-lait spots, neurofibromas, hypopigmented macules) and careful systems examination, including cardiac and neurological examination. Eyes, ears, mouths (including teeth), hands and feet, and genitals should all be examined.

Investigations are usually coordinated via specialist services, but often include bloods (including karyotyping and genetic tests), urinary metabolic screening, and imaging such as cerebral MRI (which may require a general anaesthetic).

Intellectual disability

Intellectual disability (ID) is a neurodevelopmental disorder characterised by deficits in intellectual and adaptive functioning that present before 18 years of age.¹³ The term replaces and improves upon the older term ‘mental retardation’. The term ‘global developmental delay’ (GDD) is usually used to describe children <5 years of age who fail to meet expected developmental milestones in several areas of development. Not all children with GDD will meet criteria for ID as they grow older.

Presentations include learning difficulties, language delay and behavioural problems.

The two most common causes are trisomy 21 (see CHAPTER 18) and fragile X syndrome.

Fragile X syndrome, Prader–Willi syndrome and Williams syndrome are presented in CHAPTER 18.

Cerebral palsy¹⁴

Cerebral palsy (CP) is a physical disability that affects movement and posture, and is the most common physical disability in childhood (2 in 1000 live births). Its cause is usually unknown, but CP is associated with numerous antenatal and perinatal factors, including antenatal infections (e.g. rubella, CMV), birth defects, preterm birth, IUGR, multiple pregnancy, perinatal hypoxia and postnatal head trauma or cerebral infection. It is more common with low birth weight or low socioeconomic status. It can vary from minimal to profound disability.

Definition

There are 5 key elements:

1. It is an umbrella term for a group of disorders.

2. It is permanent, but not unchanging.

3. It involves a disorder of movement and/or posture and of motor function.

4. It is due to a non-progressive interference, lesion or abnormality.

5. The interference, lesion or abnormality originates in the immature brain.

Associated impairments

• 3 in 4 are in pain

• 1 in 2 has an intellectual disability

• 1 in 3 cannot walk

• 1 in 3 requires a hip replacement

• 1 in 4 cannot talk

• 1 in 4 has epilepsy

• 1 in 4 has a behavioural disorder

• 1 in 4 has bladder control problems

• 1 in 5 has a sleep disorder

• 2 in 5 dribble

• 1 in 10 is blind

• 1 in 15 is tube fed

• 1 in 25 is deaf

Classification

Many different classification systems are used for CP. These include those based on:

• severity—mild (no restriction of activities and mobile without aids), moderate (some assistance/aids required), severe (wheelchair and marked restriction of activities)

• topographic location:

  • – paresis (weakened) vs plegia (paralysis)

  • – terms include: mono- (one limb), di- (two, usually legs), hemi- (arm and leg), para- (lower body), quadri- (4 limbs) and penta- (4 limbs and also head and neck/breathing issues)

• motor function—spastic (pyramidal) versus non-spastic (extra-pyramidal)

• muscle tone—hypertonic or hypotonic

Other terms used include ‘ataxic’, ‘dyskinetic’ and ‘athetoid’.

Diagnosis

Severely affected children are often picked up soon after birth, but mildly affected cases may not be diagnosed for years. A family doctor who has any suspicion of a disorder in movement or posture should refer the child for specialist assessment, which may include a paediatrician, a paediatric physiotherapist or a multidisciplinary team assessment.

Depending on the clinical presentation, multiple investigations may be undertaken, including visual and hearing tests, pathology tests (e.g. karyotyping, genetic testing, urine metabolic screening) or imaging such as a cerebral MRI.

Management

Management of motor and posture issues is largely the domain of therapists and specialist clinics such as a cerebral palsy clinic in a major hospital. Multiple team members may be involved, and the family doctor may be required to take a team management and coordination role. Other responsibilities that may be met by the family doctor include:

• facilitating access to funding streams and services

• diet and growth monitoring

• monitoring and treating bladder issues, including UTIs

• managing constipation issues

• dealing with pressure sores

• addressing sleep issues

• helping with behaviour issues

• looking at pain management

• addressing family issues, such as parents coping or sibling dynamics

• dealing with normal paediatric issues in general practice (e.g. immunisations, treating commonplace infections and injuries). These may present special challenges, depending on the level and type of CP

Autism spectrum disorder

In May 2013, the DSM-5¹³ made significant changes to autism terminology and classification that reflected recent research. Autism spectrum disorder (ASD) superseded autistic disorder, pervasive developmental disorder not otherwise specified (PDD-NOS) and Asperger disorder, though the latter term is also still widely used by clinicians and the public. This resulted in a change in the way autism was diagnosed, with three domains (social deficits, communication deficits and repetitive behaviour) reducing to two (social–communication deficits and repetitive behaviour). Another change is a ‘severity’ criterion that is designed to better capture the ‘spectrum’ nature of the disorder: level 3 (very substantial support), level 2 (substantial support) and level 1 (some support).

ASDs are common, with the latest Australian data putting the incidence at 1 in 160 children.¹⁵ While autism diagnoses are much more common in recent decades compared to previously (it was first described as a disorder only in 1944), whether there has been a true increase in incidence is unknown, as increasing awareness and widened diagnostic criteria make comparison with previous prevalence data unreliable.

Identification

When an autism spectrum disorder (ASD) is suspected, a GP is likely to face one of three different scenarios:

1. A family member presents with his or her own concerns about their child’s development.

2. A family member reports that a third party, such as a child-care worker or teacher, has expressed concerns about their child’s development.

3. The GP himself/herself identifies concerns with a child’s social and language development through routine developmental screening or general observation.

Scenario A should always be taken seriously, as the concerns of parents are commonly justified. Many parents present to their GP during the second to third year of their child’s life when it becomes apparent that the child’s development has stalled compared with his or her peers. While social deficits of ASD (such as delayed or absent joint attention—see below) often present earlier, they frequently go unrecognised by parents and it is usually speech delay that prompts a visit to the doctor.

Other parents may request a hearing assessment, thinking their child is deaf because he or she doesn’t respond to their name. In about 25–30% of cases there may be actual regression, with the child beginning to say words but stopping, commonly between the ages of 15 and 24 months. Parents may also report loss of eye contact and gestures such as waving or pointing.

When to suspect ASD

A typically developing child should smile in response to a familiar caregiver’s smile or ‘baby talk’ by 2–4 months. At 8 months, an infant will follow a parent’s gaze, that is, look in the same direction as the parent is looking. Children should be able to follow their parent’s point by 10–12 months and start pointing themselves by 12–14 months. They then begin to point to share (‘look at this’) by 16 months. As they point, children will look back and forth between the object and their parent—it’s the shared social experience, not the tangible object, the child seeks. These joint attention behaviours are often absent or reduced in a child with ASD.

Social deficits

Younger children with ASD often appear to have little desire to connect with others. They may have problems imitating actions (such as clapping). As they get older, individuals may have difficulty understanding the perspective of others, commonly called theory-of-mind, which in turn leads to difficulties with empathy and sharing. Affected children will often have few or no friends; higher-functioning children may desire friendship but approach peers in an inappropriate way. Inappropriate social behaviours (e.g. commenting loudly on someone’s physical appearance) can lead to problems at school. Frequently, individuals become overwhelmed by social or sensory stimulation, such as loud sounds.

Communication deficits

Communication deficits in ASD include deficits in both non-verbal and verbal communication, and expressive and receptive language. Some individuals remain mute throughout life. Although present, language may not be functional—children may be able to rote learn shapes and numbers, but not follow one-step commands. Stereotyped and repetitive language, including echolalia (‘parroting’ of learned phrases or scripts) is common. Other signs include unusual vocal qualities, such as tone or speed, and pronoun reversal (e.g. saying ‘you’ instead of ‘I’).

Affected individuals frequently have a very concrete and literal understanding of language, such as not understanding idioms, lies or jokes, and miss social cues such as body language and tone of voice. Even relatively mildly affected children (and adults) may have difficulty initiating and sustaining two-way conversations.

Children with ASD tend not to play imaginatively (e.g. pushing the car along and saying ‘brrm’) and instead will engage in unusual repetitive play, such as lining up toys, or spinning the wheels of a car. They frequently show little interest in social play (e.g. peek-a-boo or pattycake) and their play is often object-focused (e.g. computer games) rather than people-focused.

The following red flags¹⁶ are absolute indications for referral for an autism-specific assessment:

A GP-friendly screening tool for ASD is the Checklist for Autism in Toddlers (CHAT)—abbreviated version (see TABLE 94.2).¹⁷ This can be administered at approximately 18 months of age and takes only a couple of minutes.

If a child fails all three items, referral is indicated, as the chances of autism are high. If a child fails only 1 or 2 items, still refer as the chances of developmental delay are high.

Further assessment

If there are concerns that a child may have ASD, it is essential that the child is promptly referred to a general or developmental paediatrician, or to a developmental assessment unit, for an autism-specific diagnostic assessment. Taking a ‘wait and see’ approach, or saying ‘come back in 6 months and we’ll reassess’, is not acceptable. Getting hearing checked or assessments from speech therapists, occupational therapists (OTs) or psychologists may also be done in this work-up phase.

Management

Intensive early intervention for ASD, which is what guidelines¹⁸ recommend as gold standard and does improve long-term outcomes, involves intensive and often expensive behavioural/developmental therapies, and the earlier it commences the better. However, this type of therapy may be beyond the organisational and financial capability of the family, so care should be taken in what is recommended. Parents should be directed to reliable information sources^17,18 on these options, which they may find daunting. There is also a lot of misinformation on autism, particularly regarding complementary and alternative therapies, for which there is no evidence of efficacy.¹⁸ State-based autism associations can also help with advice. If the waiting times for diagnostic assessment are long (as is often the case), families should be referred to early intervention services while they wait.

The role of the GP in management

A child being diagnosed with ASD can have a massive impact on the family. GPs should monitor how family members are coping, and provide a ‘medical home’ for reliable advice on management options. Children with autism also have particular vulnerability to certain medical issues, and the GP will be involved in the management of these. These include:

• minor traumas and injuries

• restricted diet (due to sensory issues or special diets used by some families)

• behavioural issues

• constipation (due to sensory issues causing voluntary faecal retention, or from medications used for co-diagnoses)

• dental issues (sensory issues making brushing difficult, or grinding)

When consulting children with autism, special tactics can be employed to help things run smoother. Alerting front desk staff so they are aware of potential behavioural issues, allowing easier access for families in stress (e.g. calling the patient from the car if behaviour in the waiting room is problematic) and reassuring parents that challenging behaviour by the child is not an issue will help. The decreased eye contact and interaction means that the GP needs to work harder to engage these children, but it can be done, and parents will appreciate any effort made. Adjusting for sensory issues, for example, letting children hold and examine equipment before it is used, can also help.

Dyspraxia

Dyspraxia (from the Greek, meaning ‘disorder of practising’) is a disorder of the planning, organising and carrying out of motor tasks. It can affect articulation and speech, perception and thought, though it is not associated with decreased intelligence. It can vary from difficulties with simple motor movements, such as waving goodbye or clapping, to more complex issues such as handwriting or riding a bike. It is more common in males. Another term that is used is developmental coordination disorder (DCD).

If there is an issue with motor skills being delayed (without associated social and communication delay beyond motor skills) then referral to physiotherapists, occupational therapists and speech therapists, depending on the type of motor issues involved, is advisable. A delay in fine and gross motor skills can become a barrier to socialisation (e.g. not being able to play or perform in team sports) or academic achievement (e.g. writing) and can have flow-on effects on self-esteem and mood.

Specific learning disorders

A specific learning disorder (SLD) is characterised by persistent difficulties in reading, writing, arithmetic and mathematical reasoning skills during school years.¹³ The difficulties must result in abilities well below what is expected in culturally and linguistically appropriate testing. The learning issues should not be explained by other developmental, neurological, sensory (such as vision or hearing problems) or motor disorders and must significantly interfere with academic achievement, occupational performance, or activities of daily living. Dyslexia and dyscalculia are examples of SLDs.

Dyslexia

Dyslexia (from the Greek, meaning ‘disorder of words’) is an SLD of reading and spelling, while still having otherwise normal learning abilities. The condition was originally called ‘word blindness’. Also referred to as developmental reading disorder, it is not a problem of comprehension, but of the speed and accuracy of decoding (converting letters and words to sounds) and spelling (converting sounds to their correct written symbols). It can run in families. Individuals with dyslexia can have different or compensatory learning styles, but may also be helped with input from an occupational therapist or speech therapist and a dyslexia clinic.

Attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a disorder affecting attention, hyperactivity and impulse control.¹⁹ It can also affect children’s learning, social skills and family functioning. It is very common, affecting 3–5% of Australian children. It is much more common in boys. There are 3 types: predominantly hyperactive/impulsive; predominantly inattentive; and mixed, with the latter being the most common. To meet DSM-5 criteria, symptoms must be present before the age of 12, and often persist into adulthood.

Criteria¹³

Hyperactive/impulsive—6 out of 9 of the following:

• often fidgets with hands or feet or squirms in a seat

• often leaves seat in classroom or in other situations in which remaining seated is expected

• often runs about or climbs excessively during inappropriate situations (in adolescents or adults, may be limited to subjective feelings of restlessness)

• often has difficulty playing or engaging in leisure activities quietly

• is often on the go

• often talks excessively

• often blurts out answers before questions have been completed

• often has difficulty awaiting turn

• often interrupts or intrudes on others (e.g. butts into conversations or games)

Inattentive—6 out of 9 of the following:

• often fails to pay close attention to detail or makes careless mistakes in schoolwork, work or other activities

• often has difficulty sustaining attention in tasks or play activities

• often does not seem to listen when spoken to directly

• often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behaviour or failure to understand instructions)

• often has difficulty organising tasks and activities

• often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)

• often loses things necessary for tasks or activities

• is often easily distracted by extraneous stimuli

• is often forgetful in daily activities

Mixed—meets both hyperactive/impulsive and inattentive criteria.

Diagnosis

While most young children have short attention spans and are impulsive, children who meet the above criteria will stand out, and the symptoms should be displayed in more than one environment (e.g. home and school). The issue is usually raised by the parents to the GP, and a query may have been raised by an early childhood worker or teacher. Symptoms often become apparent when the child starts school, or as academic expectations start to rise around age 7–8 years. The diagnosis should be made only by appropriately experienced psychologists, paediatricians or child psychiatrists, and will require information gathered from parents, teachers or other important adults in the child’s life.¹⁹

Treatment

Children with ADHD often find their condition distressing and demoralising, and need support and understanding from family and teachers. Behavioural strategies (see TABLE 94.3) should be offered to all children, even those who do not strictly meet the diagnostic criteria but have these types of behaviours. Individual or family counselling should be considered.

Medication^20,21

Stimulants are the single most effective treatment for ADHD, and became the standard treatment in the 1980s. Controversy remains in the media, and the public are often wary, with concerns about addiction and other safety issues often raised by parents, but these fears are unfounded. While there are potential side effects, these are mostly not serious. Stimulants are often useful, and 1–2% of Australian children are put on them at some stage. Parents (and children) will frequently report a positive experience, reflecting that their previous concerns were unfounded. Eight out of ten children will find a significant improvement in their concentration, impulse control and overactivity.

Medications (4 years and older: as a rule, avoid stimulants under 4 years):

• methylphenidate (Ritalin, short acting, effect duration 3–4 hours); therapy should be started with this immediate-acting preparation

• slow-release methylphenidate (Ritalin LA 6–8 hours, Concerta 10 hours)

• dexamphetamine

• atomoxetine (Strattera)

Issues related to medication

• Can normally be prescribed only by paediatricians, child psychiatrists or neurologists

• Mechanism of action—increases noradrenalin and/or dopamine at the synapse

• Common side effects:

  • – decreased appetite

  • – poor weight gain

• Uncommon side effects:

  • – headache/dizziness

  • – stomach aches

  • – insomnia

  • – irritable, withdrawn or highly emotional

• Slight growth stunting (rarely a problem clinically)

• Slight increase in heart rate/blood pressure (not an issue unless underlying cardiac issues)

Fish oil

• Sometimes suggested for ADHD, but research is unclear about existence of and/or extent of benefit

• Contains high amounts of omega-3 fatty acids

• May help improve symptoms in some children

Oppositional defiant disorder

Oppositional defiant disorder (ODD) is defined as an ongoing pattern of anger-guided disobedience and hostile and defiant behaviour towards authority figures that goes beyond the bounds of normal childhood behavior.¹³ In the DSM-5, symptoms are grouped into three types: angry/irritable mood, argumentative/defiant behaviour and vindictiveness, reflecting the disorder having emotional and behavioural symptomatology. While such behaviours are common in early childhood, ODD should be considered when they are consistently displayed, and are impacting the family and the child’s social and educational functioning.

ODD is common (with an incidence estimated at 5–10%)²² and often undiagnosed, and has a large incidence of co-diagnosis with ADHD, with many of the symptoms crossing over between the two conditions. The onset is usually gradual, becoming evident before the age of 8. Children with ODD have a higher incidence of child abuse, school dropout and long-term mental health problems. ODD is caused by a combination of difficult temperament traits (see earlier in this chapter) and environmental factors, such as poor attachment, parenting styles or family conflict/mental health issues in parents.

Management²¹

For parents:

• improve positive parenting skills

• enhance skills in problem-solving, conflict resolution and communication

For the child:

• develop communication, problem-solving and anger management skills

For the family:

• counselling and support regarding relationships and home environment

In the classroom:

• teacher or school counsellor to provide social skills/conflict resolution skills training

There is strong evidence that psychological strategies and interventions reduce the impact of ODD on the child and family, and the earlier the better. They can also prevent progression to more serious disorders¹³ such as:

• Disruptive mood dysregulation disorder (DMDD)—characterised by severe and recurrent temper outbursts greatly out of proportion in intensity or duration to the situation >3/week for >12 months

• Conduct disorder—where there is behaviour that violates the rights of others or societal norms, such as aggression directed towards people, animals or property, often with a callous manner and lack of empathy

Tic disorders²³

Tics are sudden, rapid, recurrent involuntary vocalisations or movements usually appearing in bouts that wax and wane in intensity, frequency and type of tic. They include behaviours such as grunting, blinking, shrugging shoulders, humming, yelling out a word or phrase or clearing the throat. Tic disorders are classified into:¹³

• Tourette syndrome—motor and vocal tics for >1 year

• persistent motor or vocal tic disorder—motor or vocal tics for >1 year

• provisional tic disorder—motor and/or vocal tics for <1 year

Characteristics of tic disorders:

• average age of onset 5–6 years

• average of 5 years from onset to diagnosis

• associated with psychosocial distress and poor functioning

• strong genetic component (first-degree relatives have 10–100-fold increased risk of tics)

• associated with ADHD and OCD

• can be simple (one muscle group) or complex

• examples of complex tics (which are different from compulsions in OCD in that they are not cognitive, preplanned or anxiety reducing) include:

  • – copropraxia (making obscene gestures)

  • – echopraxia (copying others)

  • – wounding oneself

  • – echolalia (repeating others)

  • – palilalia (repeating oneself)

  • – coprolalia (uttering obscenities)

• unknown aetiology

• 80% decrease in adolescence and adulthood to no longer be an impairment

• 20% do not decrease, and may increase

• there is no treatment, other than psychosocial support and treating comorbidities

Hand-out sheets from Murtagh’s Patient Education 6th edition:

• Attention deficit hyperactivity disorder

• Autism

• Autism: Asperger’s syndrome

• Bullying of children

• Stuttering

• Tantrums