Behavioural and emotional disorders in childhood: A brief overview for paediatricians

Table 1 Subtypes of attention deficit hyperactivity disorder (based on DSM-5)

Subtypes	Predominantly inattentive (ADD)	Predominantly hyperactivity/ impulsivity	Combined ADHD
Criteria	6 of 9 inattentive symptoms	6 of 9 hyperactivity/ impulsivity symptoms	Both criteria for (1) and (2)
Details	Fails to pay close attention to details or makes careless mistakes	Squirms and fidgets
	Has difficulty sustaining attention	Can’t stay seated
	Does not appear to listen	Runs/climbs excessively
	Struggles to follow through on instructions	Can’t play/work quietly
	Has difficulty with organization	“On the go”/“driven by a motor”
	Avoids or dislikes tasks requiring a lot of thinking	Blurts out answers
	Loses things	Is unable to wait for his turn
	Is easily distracted	Intrudes/interrupts others
		Talks excessively
Other criteria	Onset before age of 12, lasting more than 6 mo, symptoms pervasive in 2 or more settings, causing significant impairment of daily functioning o development

ADHD: Attention deficit hyperactivity disorder.

Table 2 DSM-5 definition of conduct disorder and oppositional defiant disorder

Oppositional defiant disorder	Conduct disorder
A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 mo as evidenced by at least four out of 8 symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling	A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 mo from any of the categories below, with at least one criterion present in the past 6 mo
	Aggression to people and animals: (1) Often bullies, threatens, or intimidates others; (2) Often initiates physical fights; (3) Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun); (4) Has been physically cruel to people; (5) Has been physically cruel to animals; (6) Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery); (7) Has forced someone into sexual activity
Angry/irritable mood: (1) Often loses temper; (2) Is often touchy or easily annoyed; (3) Is often angry and resentful
Argumentative/defiant behavior: (4) Often argues with authority figures or, for children and adolescents, with adults; (5) Often actively defies or refuses to comply with requests from authority figures or with rules; (6) Often deliberately annoys others; (7) Often blames others for his or her mistakes or misbehavior
	Destruction of property: (8) Has deliberately engaged in fire setting with the intention of causing serious damage; (9) Has deliberately destroyed others’ property (other than by fire setting)
	Deceitfulness or theft: (10) Has broken into someone else’s house, building, or car; (11) Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others); (12) Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
Vindictiveness: (8) Has been spiteful or vindictive at least twice within the past 6 mo
	Serious violations of rules: (13) Often stays out at night despite parental prohibitions, beginning before age 13 yr; (14) Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period; (15) Is often truant from school, beginning before age 13 yr
Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic and the behavior should occur at least once per week for at least 6 mo
	The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning
The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning	If the individual is age 18 yr or older, criteria are not met for antisocial personality disorder
	Specify whether: Childhood-onset type (prior to age 10 yr); Adolescent-onset type or Unspecified onset
	Specify if: With limited prosocial emotions: Lack of remorse or guilt; Callous-lack of empathy; Unconcerned about performance or Shallow or deficient affect
	Specify current severity: Mild; Moderate or Severe
The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder	ICD-10
	It also requires the presence of three symptoms from the list of 15 (above), and duration of at least 6 mo. There are four divisions of conduct disorder: Socialised conduct disorder, unsocialised conduct disorder, conduct disorders confined to the family context and oppositional defiant disorder
Specify current severity: Mild; moderate or severe based on number of settings with symptoms shown

Table 3 DSM-5 criteria for autism spectrum disorders

Persistent deficits in social communication and social interaction across multiple contexts, as manifested by 3 out 3 of the following, currently or by history

Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions

Deficits in nonverbal communicative behaviours used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication

Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers

Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two out of 4 of the following, currently or by history

Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases)

Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day)

Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest)

Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement)

Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life)

Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning

Specify if

With or without accompanying intellectual impairment With or without accompanying language impairment

Associated with a known medical or genetic condition or environmental factor

Specify current severity based on social communication impairments and restricted, repetitive patterns of behavior

Table 4 Summary of common social communication enhancement strategies

Method	Description	Ref.
Augmentative and alternative communication	Supplements/replaces natural speech and/or writing with aided [e.g., Picture Exchange Communication System, line drawings, Blissymbols, speech generating devices, and tangible objects] and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols	[39,129-131]
	Effective in decreasing maladaptive or challenging behaviour such as aggression, self-injury and tantrums, promotes cognitive development and improves social communication
Activity schedules/visual supports	Using photographs, drawings, or written words that act as cues or prompts to help individuals complete a sequence of tasks/activities or behave appropriately in various settings	[132]
	Scripts are often used to promote social interaction, initiate or sustain interaction
Computer-/video-based instruction	Use of computer technology or video recordings for teaching language skills, social skills, social understanding, and social problem solving	[40]

Table 5 Summary of common behavioural modification strategies for management of childhood emotional and behavioural disorder

Method	Description	Ref.
ABA	Uses principles of learning theory to bring about meaningful and positive change in behaviour, to help individuals build a variety of skills (e.g., communication, social skills, self-control, and self-monitoring) and help generalize these skills to other situations	[122,123]
Discrete trial training	A one-to-one instructional approach based on ABA to teach skills in small, incremental steps in a systematic, controlled fashion, documenting stepwise clearly identified antecedent and consequence (e.g., reinforcement in the form of praise or tangible rewards) for desired behaviours	[40]
Functional communication training	Combines ABA procedures with communicative functions of maladaptive behaviour to teach alternative responses and eliminate problem behaviours	[124]
Pivotal response treatment	A play-based, child-initiated behavioural treatment, designed to teach language, decrease disruptive behaviours, and increase social, communication and academic skills, building on a child’s initiative and interests	[125]
Positive behaviour support	Uses ABA principles with person-centred values to foster skills that replace challenging behaviours with positive reinforcement of appropriate words and actions. PBS can be used to support children and adults with autism and problem behaviours	[126]
Self-management	Uses interventions to help individuals learn to independently regulate, monitor and record their behaviours in a variety of contexts, and reward themselves for using appropriate behaviours. It’s been found effective for ADHD and ASD children	[127]
Time delay	It gradually decreases the use of prompts during instruction over time. It can be used with individuals regardless of cognitive level or expressive communication abilities	[40]
Incidental teaching	Utilizes naturally occurring teaching opportunities to reinforce desirable communication behaviour	[128]
Anger management	Various strategies can be used to teach children how to recognise the signs of their growing frustration and learn a range of coping skills designed to defuse their anger and aggressive behaviour, teach them alternative ways to express anger, including relaxation techniques and stress management skills

ABA: Applied behaviour analysis; ADHD: Attention deficit hyperactivity disorder; ASD: Autistic spectrum disorder.

Table 6 DSM-5 criteria for social (pragmatic) communication disorder

Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following

Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for social context

Impairment in the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding use of overly formal language

Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction

Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meaning of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation)

The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination

The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities)

The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder

Table 7 Summary of common risk factors for development of childhood emotional and behavioural disorder

Domain	Characteristic examples	Ref.
Maternal psychopathology (mental health status)	Low maternal education, one or both parents with depression, antisocial behaviour, smoking, psychological distress, major depression or alcohol problems, an antisocial personality, substance misuse or criminal activities, teenage parental age, marital conflict, disruption or violence, previous abuse as a child and single (unmarried status)	[4,54]
Adverse perinatal factors	Maternal gestational moderate alcohol drinking, smoking and drug use, early labour onset, difficult pregnancies, premature birth, low birth weight, and infant breathing problems at birth	[55,56]
Poor child-parent relationships	Poor parental supervision, erratic harsh discipline, parental disharmony, rejection of the child, and low parental involvement in the child’s activities, lack of parental limit setting	[57,58]
Adverse family life	Dysfunctional families where domestic violence, poor parenting skills or substance abuse are a problem, lead to compromised psychological parental functioning, increased parental conflict, greater harsh, physical, and inconsistent discipline, less responsiveness to children’s needs, and less supportive and involved parenting	[59]
Household tobacco exposure	Several studies have shown a strong exposure–response association between second-hand smoke exposure and poor childhood mental health	[60,61]
Poverty and adverse socio-economic environment	Personal and community poverty signs including homelessness, low socio-economic status, overcrowding and social isolation, and exposure to toxic air, lead, and/or pesticides or early childhood malnutrition often lead to poor mental health development Chronic stressors associated with poverty such as single-parenthood, life stress, financial worries, and ever-present challenges cumulatively compromise parental psychological functioning, leading to higher levels of distress, anxiety, anger, depressive symptoms and substance use in disadvantaged parents.	[62-66]
	Chronic stressors in children also lead to abnormal behaviour pattern of ‘reactive responding’ characterized by chronic vigilance, emotional reacting and sense of powerlessness
Early age of onset	Early starters are likely to experience more persistent and chronic trajectory of antisocial behaviours	[67-69]
	Physically aggressive behaviour rarely starts after age 5
Child’s temperament	Children with difficult to manage temperaments or show aggressive behaviour from an early age are more likely to develop disruptive behavioural disorders later in life	[70-72]
	Chronic irritability, temperament and anxiety symptoms before the age of 3 yr are predictive of later childhood anxiety, depression, oppositional defiant disorder and functional impairment
Developmental delay and Intellectual disabilities	Up to 70% of preschool children with DBD are more than 4 times at risk of developmental delay in at least one domain than the general population	[15,73]
	Children with intellectual disabilities are twice as likely to have behavioural disorders as normally developing children
	Rate of challenging behaviour is 5% to 15% in schools for children with severe learning disabilities but is negligible in normal schools
Child’s gender	Boys are much more likely than girls to suffer from several DBD while depression tends to predominantly affect more girls than boys	[24,25,27,47,51]
	Unlike the male dominance in childhood ADHD and ASD, PDA tends to affect boys and girls equally

ADHD: Attention deficit hyperactivity disorder; ASD: Autistic spectrum disorder; DBD: Disruptive behaviour disorder; PDA: Pathological demand avoidance.

Table 8 Major classes of medications used in management of childhood emotional and behavioural disorders

	Common examples	Indications for use	Common Side-effects	Follow up monitoring
Traditional antipsychotics	Haloperidol, Chlorpromazine, Thiotixene, Perphenazine, Trifluoperazine	Schizophrenia, Bipolar disorder, Schizoaffective, Disorder, Obsessive-compulsive disorder, Depression, Aggression, Mood instability, Irritability in ASD	Tremors, Muscle spasms, Abnormal movements, Stiffness, Blurred vision, Constipation	Frequent blood tests (Clozapine), Blood pressure checks, Cholesterol testing, Heart Rate checks, Blood Sugar testing, Electrocardiogram, Height, Weight and blood chemistry tests
Atypical antipsychotics	Aripiprazole, Clozapine, Olanzapine, Quetiapine, Risperidone, Ziprasidone		Low white blood cell count (Agranulocytosis - with Clozapine), Diabetes, Lipid abnormalities, Weight gain, Other medication-specific side effects
Tricyclic antidepressants	Amytriptyline, Desipramine, Doxepin, Imipramine, Nortriptyline,	Depression, Anxiety, Seasonal Affective Disorder, OCD, Posttraumatic Stress Disorder, Social Anxiety, Bed-wetting and pre-menstrual syndrome	Dry mouth, Constipation, Blurry vision, Urinary retention, Dizziness, Drowsiness	Watch for worsening of depression and thoughts about suicide, Watch for unusual bruises, bleeding from the gums when brushing teeth, especially if taking other medications, Blood tests and Blood pressure checks may be needed
Selective Serotonin Reuptake Inhibitors	Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Sertraline		Headache, Nervousness, Nausea Insomnia, Weight Loss
Serotonin-norepinephrine reuptake inhibitor	Venlafaxine, Levomilnacipran, Duloxetine, Desvenlafaxine
Other antidepressants	Bupropion, Mirtazepine, Trazodone
Stimulants	Methylphenidate Immediate Release and Modified Release (e.g., Concerta XL, Equasym XL), Dexamfetamines Immediate Release and Modified Release (e.g., Lisdexamfetamine)	ADHD	Decreased appetite/ weight loss, Sleep problems, Jitteriness, restless, Headaches, Dry mouth, Dysphoria, feeling sad, Anxiety, Increased heart rate, Dizziness	Blood pressure and heart rate will be checked before treatment and periodically during treatment. Child’s height and weight are monitored
Non-stimulants	Atomoxetine
Alpha-2 agonists	Clonidine, Guanfacine		Drowsiness, Dizziness, Sleepiness
Benzodiazepines	Lorazepam, Clonazepam, Diazepam, Alprazolam, Oxazepam, Chlordiazepoxide	Anxiety, Panic disorder, Alcohol withdrawal, PTSD, OCD	Drowsiness, Dizziness, Sleepiness, Confusion, Memory loss, Blurry vision, Balance problems, Worsening behaviour	Do not stop these medications suddenly without slowly reducing (tapering) the dose as directed by the clinician. While taking buspirone, avoid grapefruit juice, Avoid alcohol, Blood tests may be needed prior to the start of treatment and during treatment
Antihistamines	Hydroxyzine HCl, Hydroxyzine, Pamoate, Alimemazine		Sleepiness, Drowsiness, Dizziness, Dry mouth, Confusion, Blurred Vision, Balance problems, Heartburn
Other anxiolytics	Buspirone		Dizziness, Nausea, Headache, Lightheadedness, Nervousness
Sleep-enhancement	Zolpidem, Zaleplon, Diphenhydramine, Trazodone	Insomnia (short-term)	Headache, Dizziness, Weakness, Nausea, Memory loss, Daytime sleepiness, Hallucinations, Dry mouth, Confusion, Blurred Vision, Balance problems, Heartburn	Blood tests may be needed before the start of treatment. Avoid alcohol

Modified from “Medications used for behavioral and emotional disorders. A guide for parents, foster parents, families, youth, caregivers, guardians, and social workers.” May 2010. Available Online: URL: http://www.ct.gov/dcf/lib/dcf/ccmu/pdf/cmcu_-_educational_booklet_5-7-2010.pdf. ADHD: Attention deficit hyperactivity disorder; ASD: Autistic spectrum disorder; PTSD: Post traumatic stress disorder; OCD: Obsessive-compulsive disorder.