Toddlers like being ‘in charge’ (as can be seen in Case 15.1). This desire is often thwarted by their abilities and the limits set by their parents. For example, 2-year-olds may want to eat their meal with their parents’ cutlery although they do not have the fine motor skills to do so, or their parents may prevent them from adding tomato sauce to their ice cream, for example.

Case 15.1

A ‘naughty’ girl

Daisy is 3 years old and her parents were anxious about her ‘extreme mood swings’. Daisy would not follow her parents’ instruction: ‘We ask her nicely but she just ignores us and if we try and make her, she goes rigid and falls to the floor’. Daisy had started to vomit during these episodes.

Her father thought that these episodes might be fits, and when they happened he gave Daisy a cuddle and comforted her. Her mother tried to ignore her but felt she had to intervene when she vomited: ‘I can’t ignore her if she’s sick’.

This lack of control causes frustration, and tantrums may follow. This is normal behaviour between the ages of 1 and 4 years.

Tantrums are usually dramatic. Crying, screaming, dropping to the floor and thrashing of limbs are common. Some children are able to induce vomiting. Occasionally these episodes may be mistaken for seizures. The key distinction is a history of provocation and the complex pattern of behaviours seen in tantrums.

Tantrums may be seen in children who receive inconsistent messages from different parents, and may in a sense mimic their parents’ behaviour. Note that children, despite appearances, never really want to ‘win the war’ – to do so would be very frightening as it would affirm their own power and destructiveness.

Management

Specific strategies

Reasonable expectations

Have a reasonable expectation of what the child is able to comply with. Excessive expectations of a child may occur with parents who themselves have unmet needs.

Ignore bad, praise good

Children want responses to their tantrums. If no reaction is gained they get bored and eventually the behaviour stops. If good behaviour is greeted with cuddles and praise, the child will seek this sort of response again. Sanctions should quickly follow bad behaviour as delayed punishment is confusing to the child and ineffective.

Time out

Place the child alone in a safe environment to calm down. This works well if used for short periods. Usually only a few minutes is required.

Consistency

Consistency of approach is crucial. Children like certainty and respond badly to the parent reacting differently on different days. They find it confusing and their poor behaviour is perpetuated. Worse, they may simply learn to read (and manipulate) their parent’s mood state, rather like a traffic light signal, instead of learning to understand the world around them.

Win sometimes

Allowing a toddler to be successful in their unreasonable demand is sometimes OK. There are some battles not worth having. Parents should only insist on compliance if able to carry out behaviour management to a successful conclusion. Anyway, only an angel or a behaviour therapist can be consistent all the time! It may be sensible to start with one specific behaviour. Do not choose the supermarket as the first arena. If the child behaves in one setting, generalization to other settings will usually follow.

Support

With the changing structure of society and families, many parents feel unsupported in managing behaviour problems. Other primary care professionals and voluntary agencies may be able to help. Befriending with emotional and material support may make the difference for vulnerable families between viability or not of the family unit.

Hyperactivity

What is attention deficit hyperactivity disorder?

The girl’s condition in Case 15.2 is an example of attention deficit hyperactivity disorder (ADHD) which is a triad of inattention, impulsivity and hyperactivity, with impairment of social or educational functioning as a consequence. In order to make the diagnosis, these difficulties should be seen before the age of 7 years and usually much younger. The patterns of behaviour need to be chronic (of at least 6 months’ duration), pervasive – i.e. they affect the child in two or more situations, such as at home, at school, or with grandparents and friends – and cause functional impairment.

Case 15.2

A girl who is always on the go

Lauren is 7 years old and had always been ‘hyperactive’. She found it difficult to concentrate on much, other than her computer. Her parents were worried about her schoolwork and her schoolteachers felt she was not fulfilling her potential. She was easily distracted in the classroom and found it difficult to sit at her table. Lauren liked school but got bored easily. She acted without thinking. She had recently been excluded from school for thumping a boy who had teased her.

What is not ADHD?

The history should not only focus on identifying the key behaviours but should highlight other biological or psychiatric explanations that might mimic these behaviours (see Box 15.1).

Box 15.1

Mimics of ADHD behaviours

Biological	Psychiatric
Hearing impairment Visual impairment Epilepsy

Autistic spectrum disorders

Parenting problems leading to insecurity

Post-traumatic stress disorder

In children, levels of activity and attention vary. This is related to age (lower in younger children), gender (worse in boys), environment and intelligence. These factors need careful consideration before labelling behaviour as ADHD. For example, in preschool children it is difficult to be certain that any pattern of behaviour represents ADHD. Many children who appear to be significantly hyperactive or inattentive at 3 or 4 years of age settle dramatically after starting school. Parental tolerance also varies. Factors such as the availability of additional welfare benefits or support may influence parental expectations. Do the parents show ADHD symptoms? Is there a dispute with the school over responsibility for conduct problems?

Family history

Family, twin and adoption studies show that ADHD has a strong genetic component. Also, later children in large families are at higher risk. One of the parents may report a similar pattern of behaviour as a child. Understanding that a parent has ADHD will help them and the child.

Making a diagnosis

ADHD, as yet, has no biological marker. No neuroimaging, genetic or metabolic studies make the diagnosis. The diagnosis is made on history and observation alone.

Information must be sought from a number of sources. This is important to establish the pervasiveness of the problem. Direct contact with the school is necessary. This information gathered may include the use of Connors’ rating scales. These are standardized questionnaires that help identify significant patterns of behaviour.

Management

Understanding ADHD

Educating the child, the family and the school about what ADHD is a crucial first step. Increasingly, schools will be familiar with the issues. Indicating to the child’s school what their ADHD-related strengths and weaknesses are is helpful.

‘Medicalizing’ patterns of behaviour, such as with ADHD, can send the wrong message to the child and family about how those difficulties have arisen and what should be done to help. It also places the doctor in the position of being the one to produce change. A wealth of written and electronic material is available to assist in communication.

An important aim is to assist the child in gaining benefits from education, the maintenance of a circle of friends, avoidance of being seen as simply ‘naughty’, and protection of family relationships.

Behavioural therapies

This attempts to modify the unhelpful behaviours. Praising good behaviour works and it needs to be immediate. Children with ADHD are unable to wait long for their reward.

Medication

Stimulant medication such as methylphenidate has had wide coverage in the worldwide press. Rightly, many groups are uncomfortable with young children being given amphetamine-based drugs. However, the 2009 NICE guidelines have recommended the use of these drugs as first-line treatment for severe ADHD. Non-stimulant drugs like atomoxetine are reserved for second-line treatment. Atomoxetine has been associated with suicidal ideation.

The mechanism of action of these drugs is via effects on dopamine neurotransmission.

For moderate ADHD, psychosocial/social intervention in the form of parent training/educational programmes should be used. If there is no response to the behavioural intervention then medication will be indicated. The ideal management course is often a combined approach of medication and behavioural therapy. The latter may be more easily utilized if children are more focused after medication.

Other

Diet

It is reasonable to suppose that what children eat affects their behaviour. Epidemiological research indicates a link between additives and preservatives in the diet and levels of hyperactivity (e.g. McCann et al. 2007). A small proportion of children may be helped by a carefully applied exclusion diet. Many parents are keen to attempt dietary manipulation. A registered dietician can support this. It is important that dietetic support is provided by an appropriately trained dietitian, as there are a variety of ‘nutritionists’ offering services privately, often with little scientific foundation.

Long chain fatty acids

Long chain fatty acids are suggested as being helpful in a number of behavioural and developmental disorders. There is some evidence that they improve ADHD behaviours.

Autistic spectrum disorders

In recent years the diagnosis of autistic spectrum disorders has become more common. Parental anxiety about autism has been further raised by controversial reports allegedly linking the measles, mumps and rubella (MMR) vaccine with autism and inflammatory bowel disease. Despite the overwhelming evidence of MMR’s safety, vaccination rates have fallen.

Case 15.3 describes a boy with autism and demonstrates some of the key features of the autistic spectrum.

Case 15.3

A boy who likes to be by himself

Jack is a 3-year-old boy. His parents were worried about his behaviour and speech. Jack only used one word ‘Thomas’, and showed no response when spoken to. He enjoyed playing with his Thomas the Tank Engine train set and liked grouping together the track and engines into separate piles. Jack preferred to play alone. He spent ages opening and closing the kitchen cupboard doors. He repeatedly rocked his body and flapped his arms. He was sensitive to loud noises and screamed and cried until they stopped.

Key features of autistic spectrum disorders

The key features begin before 3 years. They are impaired social functioning, impaired communication, repetitive behaviours and stereotyped movements. Diagnosis before 18 months may be difficult, but, in retrospect, parents may well recall very early concerns. Boys are more commonly affected.

Impaired social functioning

Children with autistic spectrum disorders struggle to interact meaningfully with the world around them and may appear aloof and indifferent. Interaction with peers and adults is on their own terms and initiated by themselves.

Impaired communication

Both expressive and receptive elements of language are impaired. Some children may never develop language and their language skills may be abnormal. Echolalia, the parrot-like repetition of words or phrases or even whole chunks out of story books, is classic, although rare. The normal intonation of speech may be absent. In severe cases, non-verbal communication with gesticulation or pointing may also be absent.

Repetitive and restricted behaviours

Children with autistic spectrum disorders do not like change. They develop routines and rituals for their day. They may be thrown by any unexpected change such as a new route to the shops. Their interests are restricted, e.g. the colour of cars or types of door handle. An ‘obsession’ with tractors for months may be followed by an equally intense interest in road traffic signals.

Normal children frequently develop special interests, but do not become obsessional to the exclusion of all else and their imaginative play is unaffected.

Stereotyped behaviours

Flapping, rocking and clapping movements are sometimes seen, especially if distressed. Tiptoe walking may be a feature.

The autistic spectrum

The patterns of behaviour characteristic of autism are the extreme end of the autistic spectrum. Less severely affected children show clear overlap with normal behaviour, and it may be more appropriate to describe these children as having autistic traits. Making a clear diagnosis in this area of overlap is difficult.

Asperger’s syndrome

Autistic spectrum disorders without significantly impaired language skills, but with social impairment, may be described as Asperger’s syndrome. Some sufferers even show gifted intelligence in particular areas, such as music, art or arithmetic.

Assessment and diagnosis

A detailed history from the parents usually highlights areas of concern. It is important to seek information from other professionals who know the child. These might include the health visitor, GP or a carer at the nursery.

Formal diagnostic tools are available to assist with diagnosis. Appropriately trained clinical psychologists, paediatricians or child psychiatrists usually conduct these.

Causes of autism

These patterns of behaviour are increasingly being recognized as attributable to a medical cause. Genetic markers for autism have been identified but are not yet useful as a diagnostic tool.

One widely regarded theory is that part of the problem can be explained by the child’s lacking a sense of others having a separate point of view (theory of mind). Without that understanding, interpersonal relationships are impossibly confusing and the child withdraws.

Being a ‘bad parent’ is never a cause of autism. Acquisition of good expressive language by the age of 5 years indicates a reasonable prognosis.

Intervention

Intervention begins with early diagnosis. Interagency agreement about diagnosis and joint planning of intervention is essential (see also Chapter 3, p. 20). Key individuals include speech and language therapists, educational and clinical psychologists, specialist nurses and ideally an identified key worker to help the family negotiate the bureaucratic maze. Special schooling may be necessary. Transition to adult services is often fraught, as support is much less readily available.

Depression

Case 15.4

A sad teenager

Laura, aged 14 years, presented to her GP with somatic complaints. The GP perceptively noted that these followed the death of her grandmother. Chronicity of the symptoms and school absence prompted the doctor to suggest depression as the cause, but the family was reluctant to accept a psychiatric referral so she was referred to the paediatric clinic.

What is depression?

The resilience of children to cope with stress, including bereavement (as in Case 15.4), is dependent on the child’s previous experiences coupled with the number and severity of other problems they have to face. A seemingly minor event may be more significant for a child than the parents realize (e.g. the death of a pet, loss of a friend) and normal sadness gives way to depression. There may be a family history of depression. Symptoms include diurnal variation in mood, being worse in the morning, irritability, low energy, poor self-esteem and thoughts of suicide. Interviewing the child may well elicit symptoms otherwise unknown to the parents. Poor appetite, sleep problems and other psychiatric conditions may be present.

Management

An experienced psychologist may be able to further clarify the diagnosis with the aid of appropriate rating scales. These can also be used to monitor progress. Psychological therapies are usually effective. Current NICE guidelines (October 2005) recommend cognitive behavioural therapy (CBT) for mild to moderate depression in adolescents (<18 years). Antidepressants should be used in conjunction with CBT in severe depression or if the patient is unwilling to try psychological intervention. CBT is used to explore the child’s recurrent negative thoughts about self-worth and possibilities for change. Behavioural management includes maintaining activity and social contacts. Antidepressants should only be used under the direction of a child and adolescent psychiatrist.

Deliberate self-harm

Whereas only a minority will be seriously mentally ill, all children and adolescents who self-harm deserve careful professional assessment. Thoughts of suicide are relatively common but are less often acted upon. Self-harm increases in the adolescent years, especially in girls. Poisoning is the commonest method; however, self-harm resulting in death is very uncommon. Repeated self-harm attempts are not uncommon. Ten per cent will harm themselves again within a year.

Good liaison needs to be established between the acute paediatric unit and the local Child and Adolescent Mental Health Service (CAMHS) which are likely to be seeing several such cases each week. A member of the CAMHS team should assess all children with self-harm, whether admitted or not.

The CAMHS team will explore what background factors are relevant, including family or peer problems, other social and emotional stressors and child abuse. Family members will need to be seen. Gentle enquiries by paediatric staff can help, but intrusive questioning should be avoided, especially if sexual abuse is suspected. Early disclosures may be subsequently withdrawn if not carefully handled. However, most patients will volunteer recent social stressors, express embarrassment, and declare a wish to not repeat the behaviour. Most will describe an immediate precipitant – typically a row – indicating a lack of serious forward planning.

School refusal

Difficult transitions in childhood can precipitate the onset of behaviour which presents to the doctor as ‘illness’ (as in Case 15.5). Perhaps it is better to view the child as stuck in a ‘predicament’ that brings him to professional attention.

Boys and girls in equal measure may try to avoid going to school, sometimes by playing truant, sometimes through symptoms of illness (‘somatization’). School refusal usually boils down to anxiety about change, separation from parents and family conflict, or fear as a result of bullying and, perhaps, for the health or safety of a parent. The parents are often ambivalent about school, which may contribute to the child’s sense of insecurity and anxiety. The child may be grieving or depressed. Bullying, or fear of a particular lesson, may play a part, but changing the school regime or even changing school often fails to solve the problem.

Case 15.5

A boy who does not like school

Edward had been at high school for one term. At the start of the spring term he had had a week off with tonsillitis and had been reluctant to go back to school since then. He perked up at the weekend, but by the Sunday evening complained of a sore throat and felt too unwell to go on the Monday morning. The more he was challenged, the more it seemed that his conduct was manipulative of his exhausted parents. His father thought he needed a firm hand but his mother disagreed.

The term ‘school phobia’ has been used, despite the fact that the child is not usually phobic about school. Nevertheless, getting the child back into school as quickly as possible is often the best way to overcome the problem, demonstrating to the child and family that school is not as bad as anticipated. Good liaison with the local education welfare service is essential. The child and parents need reassurance that it is medically safe to go to school. Addressing underlying separation anxiety or family problems, or an entrenched pattern of non-attendance, may require the skills of a child psychiatrist. Return to school is the norm, but more anxiety or phobic problems may emerge in later life.

Truancy

School refusal is distinct (at least in theory) from truancy, which is a term referring to a child who, for example, leaves home in the morning as if to go to school, but decides to do something more interesting instead. Social truanting with others may lead to delinquency. Isolated truants are more likely to be emotionally disturbed or otherwise unhappy or distressed.

Chronic fatigue syndrome/myalgic encephalomyelitis

Case 15.6

A boy who is tired all the time

Ben was 12 years old. He had not been to school for 4 months. His tiredness started 9 months before with a throat infection that his GP thought was glandular fever. His mother was concerned that his immune system was not working properly and that that was why he was so tired. She thought he needed investigating. Ben was worried about becoming more active as he had started to feel a little better recently and thought he might relapse. Ben’s school had stopped sending work home for him since his parents had arranged a home tutor.

The diagnosis of CFS/ME should be considered in any child with persistent or, less commonly, recurrent symptoms of fatigue, often with post-exertional malaise, and consequent reduction in activity levels. The majority of children fall into three distinct symptom complexes:

It is important to investigate cases of fatigue carefully. Exclusion of medical causes for the symptoms must occur before embarking on managing the problem as CFS/ME. This certainly includes a detailed history and examination. It usually involves investigations such as full blood count and iron stores, electrolytes, kidney, liver and thyroid function.

It is important to ask the child and the family what their ideas are about this illness. Addressing these ideas and beliefs is a crucial step in the management. Explore the child’s social anxieties as there may be hidden problems impeding recovery.

Management

General principles

It is important to formulate an individualized management plan, in conjunction with the child/family. In addition to the mainstays of treatment, graded exercise therapy and/or CBT, the plan should address the patient’s specific symptoms. Pain symptoms are often prominent, but commonly poorly responsive to analgesia, and referral to a specialist pain team may be needed. Disordered sleep with poor sleep hygiene, may aggravate daytime fatigue and should be addressed within the management plan. The plan should set out specific care and treatment for symptom relapse, and support the child’s educational and psychological needs. The plan should be reviewed regularly. Failure to respond adequately should prompt referral to a specialist CFS/ME service.

Graded exercise therapy

A structured increase in physical activity helps to alleviate the symptoms of fatigue. This should include a planned increase in school attendance. This programme needs to be agreed by the child, the family and the school. The rate of increase in activity is not important. However, every step up should be maintained. Some aspects of this programme, particularly any exercise elements, may benefit from the supervision of a physiotherapist and/or occupational therapist.

Cognitive behavioural therapy

This aims to change a child’s thought processes, behaviours, physiological responses and environment. It requires a skilled therapist to use this to target the thoughts and overt behaviours that might be perpetuating the symptoms of fatigue.

Outcome

The great majority of children recover, but this may take time. Many miss significant amounts of school and take years to regain full levels of activity. Co-morbid features such as school refusal and depression worsen the prognosis if not adequately addressed.

Substance abuse

Case 15.7

A boy smoking dope

Tom was 15 years old and had been excluded from school. He was caught smoking cannabis at the bottom of the school playing field. His parents were concerned that his habit would lead to a wider drug problem and wanted to find Tom some help with giving up. Tom did not see what the problem was: ‘Dad smokes and they both drink – that’s more harmful than what I do’.

Children and adolescents are exposed to a variety of legal and illegal substances and the health effects vary. Rarely, acute intoxications of drugs or alcohol lead to hospital admission. Usually these behaviours do not precipitate immediate health problems, but can be the start of dependency or addiction that persists into adult life. The commonest substances used are tobacco and alcohol. Other than marijuana, illicit drug use under 16 years is relatively uncommon. As Case 15.7 illustrates the issues around these behaviours are complex both for families and society.

Smoking

In 2009 the proportion of English children who reported smoking at least one cigarette a week was 6% in those aged 11–15. Almost one-third of the children had tried smoking at least once. Girls were more likely to be regular smokers, and the prevalence increased with age. The health risks of smoking are well established but the incidence of smoking has remained static. Children start smoking for a number of reasons. The attitudes of their peers and siblings strongly influence children. The smoking habits of their parents similarly contribute to how socially acceptable it is for the child to smoke. Children whose parents smoke are more likely to start smoking. Children themselves report that tobacco advertising influences their decision to start smoking and which brands they smoke.

Alcohol

Regular alcohol consumption is common in older children. In 2009, 18% of boys and girls in England, aged 13–15 years, reported drinking alcohol in the past week. This proportion has decreased from 26% in 2001. Among those who drank, mean consumption in the past week was estimated as 11.6 units per week, with no significant difference between boys and girls. Drunk children are at risk of accidental injury and alcohol poisoning. Unplanned and unprotected sex may occur.

Cannabis

Cannabis is by far the most common illegal substance used by children. Since 2001 there has been a decline in cannabis use from 13.4% to 8.9% in 2009. In England and Wales, approximately 9.8% of boys and 8.1% of girls have tried the drug. The risks of cannabis are increased by regular and heavy use. This appears uncommon in children. Cannabis may cause a range of mental health problems, including acute anxiety and psychotic states.

Advice and support

National initiatives such as ‘Connexions’ and ‘Talk to Frank’ provide useful information to young people and families about these issues. Local support varies. For more significant drug use either in terms of frequency or substance, support from adult-orientated drug and alcohol services may be of help. Child and adolescent mental healthcare services may be similarly helpful.

Always consider the reasons why a child has become involved in these behaviours. To many children, drinking, smoking and cannabis use is part of ‘growing up’. To others it may represent an escape from a difficult family or social circumstance. These children may at least need advice and support, and some will need protecting.

Eating disorders

Food refusal

Some infants and young children persistently fail to consume adequate food, which affects their growth and development. It is usually helpful to view this as the outcome of subtle interactive difficulties between parent and child. Careful observation of feeding times, coupled with a detailed family history, will help discover the broader issues. Help for the parents, as well as the child, will need to be organized if problems persist.

Anorexia nervosa

Anorexia nervosa usually presents with insidious weight loss, often with excessive exercise and always with deception around food intake (as in Case 15.8). The child may like cooking and food, but denies having an appetite. Anorexia nervosa is much commoner in girls (the male to female ratio is 1:10), with as many as 1% of adolescent girls being affected. The characteristics are inappropriately low body weight (<15% under expected weight-for-height), intense fear of fatness, even when weight loss is achieved, and disordered body image, usually with accompanying physical sequelae such as amenorrhoea.

Case 15.8

A girl who thinks she is fat

Lucy is 14 years old. Her mother had taken her to see the doctor because she was uncertain about her daughter’s weight loss. Lucy had been a little chubby 6 months previously, but had lost significant weight since then. The mother was initially rather pleased, as she herself had never been comfortable with people who over-eat. Lucy had started to refuse to sit down for any family meals. She exercised whenever she could, and had become very prudish about being seen undressed. The doctor discovered that she had been taking laxatives without her mother’s knowledge. Lucy insisted all was well but half admitted to relationship problems with her friends at school.

Self-esteem is low, but the child usually denies emotional difficulties. The widening social life and sexual challenges of adolescence may well present the child with overwhelming anxiety, and a need to regain a sense of control over her life and her body. Denial of food stands symbolically for mastery over emotional turmoil.

Examination should include repeated weight measurements (at least weekly) in underwear and on the same scales. Where possible, female staff should weigh and measure. Lanugo hair may be seen. Blood pressure and the body mass index should be recorded.

Management involves stabilization of weight and exploration of the control issues beyond the food obsession. Confident handling reduces anxiety in both child and parents. Beware of the parents who are excessively enmeshed in the child’s problems and who subtly undermine and frustrate the therapeutic regime.

The management of anorexia should be supervised by a child psychiatrist. Early referral and treatment is important. Partnership between paediatric services, child psychiatry/psychology and primary care is needed.

Cognitive therapy can be useful in challenging the child’s mistaken negative thoughts about herself. Inpatient care should be avoided unless essential. It may be needed to stabilize weight. Wherever treated, advise on realistic weight for age, and target rates of gain (not to be exceeded or under-achieved) should be set for gradual improvement over a period of weeks. It is vital to address the child’s underlying feelings. Low mood is common but usually resolves with weight gain.