As for autism, but fewer motor mannerisms Cognitive functioning 70% associated with intellectual disability Normal range of IQ Onset of problems Before 3 years of age Usually later (i.e. present in primary school) Comorbidities Significant behavioural and learning difficulties Increased risk of psychological/psychiatric difficulties, especially adolescents

Management requires a multidisciplinary approach as for children with intellectual disability. Medication may be useful to target problematic behaviours (e.g. repetitive head banging), particular symptoms (e.g. poor sleep) or comorbid psychiatric disorders; however, they need to be used with care and as part of a holistic package of care.

CASE EXAMPLE: autism

A 4-year-old boy was brought by his parents because they were concerned about his very limited speech and odd use of language (including pronoun reversal and echolalia). They also reported that he did not like being cuddled and ignored other children, preferring to spend hours lining up his collection of toy trucks and tractors. He also did not respond when he was called. He would wear only Thomas the Tank Engine long-sleeve tops regardless of the weather. He hated the feel of water on his head and washing his hair resulted in a major tantrum. He repeated phrases from the Thomas the Tank Engine DVD and became extremely upset if this was interrupted. Diagnosis was of autism and moderate intellectual disability. Management included enrolment in an early childhood intervention program to assist with improving social interactions and communication, parenting strategies for managing difficult behaviours, and advice regarding educational needs. The latter are probably best met in a specialist school setting.

Elimination disorders

Bowel and bladder control are usually achieved by the age of 4 years. Enuresis and encopresis (respectively wetting and soiling not due to a physical cause) may be part of maturational delay, a response to transient stress in the child’s life (e.g. change of school or birth of a sibling), or a sign of more significant emotional difficulties (e.g. anxiety).

Management

Exclude a physical cause.

Evaluate the home and school environment to identify possible precipitants (e.g. marital discord or bullying).

Provide psychoeducation for parents.

Implement non-punitive strategies to assist the child with toileting (i.e. reminders, limit fluids in the evenings and assist child to get up at night to go to the toilet for nocturnal enuresis).

Use operant conditioning; using a ‘bell and pad’ can be very effective.

Address the underlying cause, if ‘secondary’.

Primary school children: 5–13 years

Box 16.3 lists disorders of primary school children.

BOX 16.3 Disorders of primary school children

Disorders in this age group include:

• anxiety disorders

• learning disorders

• disruptive disorders such as attention deficit hyperactivity disorder (ADHD), and

• oppositional defiant disorder and conduct disorder.

Anxiety disorders

Anxiety is expected and normal at specific times in development (e.g. distress in a preschooler separated from their parents). Many children have short-lived fears such as fear of the dark, storms or animals.

Anxious children are often overly tense, but they can also be quiet and compliant and therefore not diagnosed.

For it to be a disorder, the level of anxiety must interfere with the child’s usual activities. Common childhood anxiety disorders are shown in Table 16.3. For more information on anxiety disorders, see Chapters 8 and 9.

TABLE 16.3 Childhood anxiety disorders

Disorder	Core features
Separation anxiety	Constant fears about the safety of parents/carers Frequent stomach aches/physical complaints Distress at times of separation from parents; overly clingy Trouble sleeping or nightmares; extreme worry about sleeping away from home School refusal

Specific phobia

Extreme fear of a specific thing or situation

Fears interfere with usual activities

Social anxiety

Fear of meeting or talking to people

Avoidance of social situations

Few friends outside the family

Generalised anxiety

Worries about things before they happen

Constant worries about family, school, friends and activities

Fear of embarrassment or making mistakes

Low self-esteem; lacking in self-confidence

Obsessive-compulsive disorder (OCD)

Commonly begins in childhood and has a waxing and waning course

Symptoms are often not experienced by the child as ego-dystonic

Unwanted thoughts (obsessions); repetitive actions (compulsions)

Management

Evaluate the child, family and environment to identify possible precipitating, contributing and perpetuating factors.

Interventions are a combination of individual and family strategies. Involving parents is critical to the success of the management plan.

CASE EXAMPLE: anxiety disorder

A 10-year-old girl presented with a number of somatic complaints and was refusing to go to school. She had been described as always being a ‘worrier’, but this had intensified following the death of her grandmother 4 months previously. She had become increasingly clingy and irritable and was having difficulty getting off to sleep. Specifically, she was worried that something might happen to her parents. Management included individual work, including relaxation techniques and exploration of loss and grief issues. Psychoeducation and parenting strategies were provided to assist her parents to reassure her appropriately and help manage her anxiety and minimise avoidance. Liaison with her teacher regarding her return to school and managing her somatic complaints were also important.

Learning disorders

Parents are often worried when their child has learning difficulties at school. There are many reasons for school failure, but a common one is a specific learning disability. Learning disorders affect about one in ten children, often run in families and are often not recognised. They are believed to be caused by perturbations of brain functioning that affects receiving, processing and communicating information. Commonly, a child will fail to master reading, spelling, writing and/ or maths skills despite trying hard to learn, or will have problems with language or motor skills (see Table 16.4). This needs to be distinguished from school underachievement due to other factors such as non-attendance or depression.

TABLE 16.4 Learning disorders of childhood

Disorder	Feature
Communication disorders	Expressive language disorder Receptive language disorder Mixed expressive/receptive language disorder

Motor skills disorder

Slow to develop motor coordination

Overly clumsy; poor handwriting

Specific learning disorders (academic skills)

Reading disorder

Mathematics disorder

Written language disorder

Secondary problems of poor self-esteem, misbehaviour and school refusal may arise if the difficulties are not identified and specific interventions put in place. Co-occurring ADHD and learning disorders are common. Diagnosis is made on the basis of standardised assessments of speech, educational attainments or coordination (occupational therapy assessment). The diagnosis can be easily missed if not thought about. Specific interventions to address these difficulties are required in addition to psychoeducation for parents and teachers.

Attention deficit hyperactivity disorder (ADHD)

The main features of ADHD are shown in Table 16.5. Difficulties are present from early childhood, more severe and frequent than other children of the same age or developmental level, and present in multiple settings (i.e. home and school).

TABLE 16.5 The main features of ADHD

Feature	Characterised by:
Hyperactivity	‘On the go’ all the time Fidgets and squirms Runs around or climbs excessively

Impulsivity

Blurts out answers; talks too much

Has trouble taking turns

Interrupts others

Inattention

Easily distracted; has trouble listening

Inattention to details; makes careless mistakes

Loses things

Has trouble finishing tasks

Secondary problems of poor self-esteem, poor peer relationships and school failure are common. Comorbid disorders might include anxiety, depression, conduct disorder and learning disorders. In the differential diagnosis, consider ‘normal’ behaviour, parenting issues and attitudes, and trauma or neglect, as traumatised children can be hyper-vigilant, reactive to the environment and have poor concentration.

Management

Management is multimodal, including parenting techniques (clear instructions, consistency, appropriate praise and reward), classroom strategies (seating close to the teacher, information in small amounts, short breaks) and medications to reduce the target symptoms. In addition, remedial teaching, identification and interventions for specific learning disorders, and addressing issues of poor self-esteem and social difficulties are crucial.

Oppositional defiant disorder (ODD)

Children with ODD demonstrate a persistent pattern of uncooperative, defiant and hostile behaviour towards authority figures, which affects their social, family and academic life (Box 16.4). These behaviours are seen in multiple settings, including home and school.

BOX 16.4 Symptoms of oppositional defiant disorder (ODD)

Symptoms of ODD include:

• frequent temper tantrums

• arguing with adults

• refusal to comply with adult requests or rules

• deliberately annoying others, and

• blaming others for their mistakes.

Such behaviours may be part of normal development for a 2- or 3-year-old, and adolescents tend sometimes to be oppositional, disobedient and uncooperative. Thus, labelling a child as ‘oppositional defiant’ needs to be done according to the developmental context. Some children with ODD go on to develop conduct disorder.

Management

Management includes parenting skills training and the identification and treatment of comorbid conditions such as anxiety, depression and ADHD. The family environment and parenting issues should also be addressed, and specific interventions provided should the child have been the victim of trauma.

Conduct disorder

Children with conduct disorder show serious difficulty following rules and behaving in socially acceptable ways (see Table 16.6). Onset may be in childhood or adolescence, and these children are often viewed by others as ‘bad’ or delinquent rather than mentally unwell. The behaviours often lead to school expulsion, out-of-home care and involvement of the youth justice system.

TABLE 16.6 Features of conduct disorder

Feature	Characterised by:
Aggression to people and animals	Bullies, threatens or intimidates Initiates fights; has used a weapon Physically cruel to people or animals Forces someone into sexual activity Steals from a victim while confronting them

Destruction of property

Deliberately engages in fire setting with the intention to cause damage

Deliberately destroys others’ property

Deceitfulness, lying, stealing

Has broken into houses/cars

Lies to obtain goods/favours or to avoid obligations

Steals items without confronting a victim

Serious violation of rules

Often stays out at night

Runs away from home

Truant from school

The aetiology is multifactorial, including brain damage, child abuse, genetic vulnerability and traumatic life experiences. Comorbidity is common and includes mood disorders, anxiety, PTSD and substance abuse.

Management can be difficult, and early identification and treatment is likely to have best results. Interventions need to target the child, the family and the system, encompassing:

identify underlying factors (e.g. child abuse)

parenting strategies and family work

problem-solving strategies, and

identification and intervention for comorbid conditions.

CASE EXAMPLE: disruptive behaviours in a teenager

A 13-year-old boy was referred by the juvenile justice system following being charged with car theft. He had been a client of the child protection system for 2 years and had been placed in ‘out-of-home care’ because of inadequate parental supervision at home. He had a long history of getting into fights and being verbally aggressive, and had been expelled from two schools. Since being in foster care, he had started using inhalants and smoking marijuana. He frequently absconded from his placement and went home to his mother’s house or simply went missing. He had a long history of academic difficulties and his IQ was in the borderline range. Management was multimodal and incorporated interventions at the child, family and systems levels. These included mental state and risk assessment, and addressing the substance use. Appropriate school placement, involvement in suitable activities, and support for both his mother and foster parents were addressed. This included appropriate limit setting and the building in of consequences for errant behaviours.

Adolescents and youth: > 13 years

Box 16.5 lists disorders of adolescence and young

BOX 16.5 Disorders of adolescence and young adulthood

Disorders include:

• depression

• deliberate self-harm, and

• substance use (see Ch 20).

Depression

Depression affects about 5% of children and adolescents in the general population, with a higher risk in those with comorbid attentional, learning, conduct or anxiety disorders, substance abuse, or those who experience loss or ongoing stress. Changes in behaviour may be the first sign, rather than mood difficulties (see Table 16.7). There may be associated reckless behaviours, deliberate self-harm or suicide attempts (expressly in adolescents). For more information on depression, see Chapter 6.

TABLE 16.7 Features of depression in adolescence and young adulthood

Feature	Characterised by:
Mood changes	May be sad, tearful and anxious, or irritable and angry (especially adolescents) Extreme sensitivity to perceived rejection or failure

Cognitive changes

Poor concentration

Overwhelmingly negative thoughts

Thoughts of hopelessness, guilt, low self-worth and low self-esteem

Thoughts of ‘not wanting to be around’, self-harm or suicide

Functional/behavioural changes

Disruptive behaviour at home or school

Decreased interest/pleasure in usual activities

Social isolation, no longer playing/spending time with friends

Relationship difficulties

Decreased school performance

Deliberate self-harm

Physiological changes

Changes in appetite or sleeping patterns

Low energy levels

Frequent physical complaints (especially younger children)

Management

Address the risk issues and implement a safety plan.

Identify stresses, such as school, peers and family relationships.

Use non-pharmacological modalities, such as cognitive behaviour therapy (CBT), problem-solving skills and family work.

Use medications with caution. There is little evidence for the efficacy of antidepressants in adolescents.

Monitor carefully, especially mental state, risk, response and side effects.

Address comorbid conditions (e.g. drug and alcohol use).

Deliberate self-harm

Self-injury is a complex behaviour that results from a variety of factors, including those shown in Table 16.8. Self-harm can take many forms, including minor skin scratching, marking, picking, burning, overdose of prescribed and non-prescribed substances, head banging, bruising and reckless behaviour. The behaviours may overlap with thoughts of wanting to die or suicide.

TABLE 16.8 Factors that might contribute to self-harm