Fussy Eaters, Poor Sleepers and Tantrumming Tots Behaviour Issues in Young Children

Transcription

1 Fussy Eaters, Poor Sleepers and Tantrumming Tots Behaviour Issues in Young Children Dr Liberty Gallus, Paediatrician Director, Child Development Unit

2 Outline > Influences on child behavior > An approach to assessment > Summary of what is normal > Red Flags > Information about common disorders > Referral and support options > Resources

3 Behaviour Issues in Children > Are common > Present in a range of ways > Are often complex and can be difficult and time consuming to assess and manage > Children behave the way they do for a reason there is no such thing as a naughty child!

4 General Approach > Is this a simple behaviour problem, or is there something else going on? > Refer children and families who need it: Further assessment diagnosis not clear Definitive diagnosis suspicious of a diagnosis Assistance with management > Manage those who do not require referral: What is the behaviour telling me? Devise management plan Monitor

5 Influences on Child Behaviour > Normal social-emotional development requires a bond with a primary caregiver and adequate social interactions > Home environment / parenting routine/chaos, predictable/variable, emotionally responsive, limit setting > Temperament > Disease / disability > Educational environment > Sleep > Diet

6 Where to Start? > History of the behaviour: What? How long? How often? Where? With whom? When? Why now? Who is worried and to what degree? What are they worried about?

7 Further History > Past medical history from pregnancy onwards > Family tree and family history > Do you or Johnny s father have any medical or mental health issues that impact on the family? > Finances > Current and previous supports and services

8 Further History > Has Johnny ever been exposed to verbal aggression or physical violence within the immediate or extended family, or the neighbourhood? > Sleep > Diet > Attention Span screen entertainment doesn t count > Impulsive? > Easily distracted? More so than peers? A problem? > Total screen time per day

9 Examination > Observe child s behaviour > Observe carer/child interaction > Take note of developmental level > General physical exam incl. growth, ENT, skin and central nervous system > Look for Red Flags

10 Developmental Screening Tools > Ages and Stages Questionnaire 3 rd Edition (ASQ-3) > Parents Evaluation of Developmental Status (PEDS)

11 Behaviour/Emotion Screening Tools > Strengths and Difficulties Questionnaire (SDQ) ages 3-16 years > Ages and Stages Questionnaire Social-Emotional 2 nd Edition (ASQ:SE 2) - ages 1 month 5 years

12 Are There Underlying Issues? Child Factors Child Behaviour Relationship Factors Parent Factors

13 Child Factors > Developmental Disorders ADHD ASD > Developmental Delays Global Language > Mental Health Anxiety PTSD > Hearing Impairment > Illness GORD Eosinophilic oesophagitis Food Intolerance Fe Deficiency Sleep Disordered Breathing / Obstructive Sleep Apnoea

14 Parent Factors > May impact on parenting and thereby cause behaviour issues, or cause reduced tolerance for normal age appropriate behaviour Mental Illness Substance Abuse Physical Illness

15 Relationship Issues > Domestic Violence > Child Abuse > Attachment

16 Behaviour: What s Normal? At Months: >Begin to show negative emotions - may resist naps, refuse some foods, tantrum >Afraid of being away from carer, hence sleep issues

17 Behaviour: What s Normal? At 2-3 Years: > May shows extremes of behaviour > Get angry when stopped doing something > Temper tantrums are common > Easily distracted and short attention span > Little concept of sharing > Like routine > Afraid of noises > Separation from parent, is still frightening, especially at bedtime

18 Behaviour: What s Normal? At 3 4 Years: >Self-centered and may feel responsible for everything that happens At 4 5 Years: >May still show stubbornness, aggression and blaming others for their behaviour At 5-6 Years: >Shows anger by slamming doors, stamping of feet, I hate you >Less frustrated and angry

19 Behaviour: Red Flags > Sudden behaviour change (consider acute illness) > Delayed development / Language delay > Loss of skills > Persistent / worsening issues > Failure to respond to usual interventions

20 Tantrums: What s Normal?

21 Tantrums: Red Flags 1. Frequent aggression toward caregivers, objects, or both 2. Self-injury e.g. biting, scratching, head banging 3. More frequent tantrums 4. Very long tantrums 5. Inability to calm after a tantrum

22 Sleep: What s Normal? > Toddlers (1-2 years) need hours per 24 hour period > Preschoolers (3-5 years) need hours per 24 hour period

23 Sleep: Red Flags > Frequent loud snoring > Pauses in breathing when asleep > Snorting/waking suddenly from sleep > Excessive daytime tiredness / irritability / hyperactivity > Large tonsils

24 Feeding: Red Flags > Crossing percentile lines on the growth chart > Gastrointestinal symptoms (e.g. vomiting, diarrhoea, mouth ulcers, food sticking, choking) > Low energy > Atopy / reactions to foods > Consistently taking more than 45 minutes to eat a meal > Regularly has severe tantrums or aversive behaviours when presented with food or the highchair > Cannot eat without major distraction or entertainment > Family experiencing problems around feeding mealtimes are unpleasant From: Red Flags for children birth to six years

25 Language Delay: Red Flags > No babbling by 9 months > No first words by 15 months > No word combinations by 24 months > Regressing or stagnant speech development > Problems understanding child's speech at 24 months of age; strangers having problems understanding child's speech by 36 months of age > Not showing an interest in communicating From:

26 Attachment Issues: Red Flags > When a primary caregiver is frequently displaying any of the following: Unable to respond appropriately to child s cues Responds inconsistently to child s cues Frequently ignores or rejects the child Speaks about the child in negative terms Often appears to be angry with the child From: Red Flags for children birth to six years

27 Attention Deficit Hyperactivity Disorder (ADHD) > I rarely diagnose < 5-6 years > Assessment is complex & lengthy > Need to rule out developmental/mental health issues > Need information from as many sources as possible > Use ADHD Rating Scales to support diagnosis (Vanderbilt, SNAP-IV) > Comorbidities are commmon > Medication: Start only after a trial of strategies Aims to improve learning NOT behaviour

28 Autism Spectrum Disorder (ASD) > Lifelong developmental disorder present from birth > Common (1:85) > Can be diagnosed as early as 12 months so don t wait to refer > Deficits in both social communication and restricted and repetitive behaviours. > First concern may be from staff at childcare/kindy/school > Ax is lengthy and complex > Cannot Dx (or rule out) in a single consultation > May display normal behaviours (and typically developing children may display abnormal behaviours)

29 ASD > Screening tools can help but aren t that reliable M-CHAT-R/F months ASDetect App > Bottom line if thinking about ASD - REFER

30 ASD: Red Flags > Social communication The child DOES NOT: > show people things, share experiences > use eye contact to get someone s attention > consistently respond to her name > spontaneously smile at caregivers > spontaneously use gestures > show interest in other children > start social games such as peekaboo > engage in pretend play > understand simple one-step instructions From:

31 ASD: Red Flags > Restrictive and Repetitive Behaviours The child: > copies what she hears from others or from the TV (echolalia / stereotyped language) > has an intense interest in certain objects or toys > interacts with toys and objects in one particular way for example, wheel turning or lining up objects > is very interested in unusual objects or activities > focuses narrowly on objects and activities > is easily upset by change and must follow routines > unusual body movements > is extremely sensitive to sensory experiences > seeks sensory stimulation From:

32 Child Abuse > Behaviour issues may be an indicator of abuse > Children with behaviour issues are also at increased risk of abuse > Some factors place a child at increased risk of both behaviour issues and abuse e.g. Developmental delays and disorders Chronic illness Prematurity Social factors

33 Referral / Support Options > General Paediatrician > Hospital OPD > Private > For: just about everything! > Child and Family Health Service (CaFHS) > Nursing > For: support for preschoolers, feeding/sleeping/be haviour, developmental screen (ASQ/Brigance) > Metropolitan, Regional and Rural Locations

34 Referral / Support Options > Child and adolescent Mental Health Service (CAMHS) > Multi-discipline > Wait list > Not a diagnostic service > For: behaviour issues when possible mental health issues > Metropolitan, Regional and Outreach Services > Community Health Services > 4 years > Psychology/Speech Pathology (SP)/Occupational Therapy (OT) > For: developmental issues, behaviour/sleep/feedi ng, attachment > Metropolitan and regional

35 Referral / Support Options > Department for Education and Child Development (DECD) > Kindys and schools > Limited SP and psychologist assessments > SP support > Children s Centres > DECD > SP/OT > 0-4 years > Co-located with Child cares > For: developmental concerns, parenting > Metropolitan and regional

36 Referral / Support Options > Child Development Units > Lyell McEwin, WCH & FMC > Accept referrals from GPs on specific referral forms > Long waiting lists > Do not provide ongoing therapy > For: assessments > Public Speech Pathologist > Hospitals > For: feeding only > Private Speech Pathologist > Medicare Plans > For: language & feeding issues > Some assess for ASD

37 Referral / Support Options > Private Psychologist > Medicare Plans >?Access to Allied Psychological Services (ATAPS) > For: Behaviour issues incl. sleep, feeding, tantrums, defiance etc. Relationship based therapy Strategies for ADHD Some assess for ASD

38 Referral / Support Options > National Disability Insurance Scheme Early intervention > Autism SA > Do not provide developmental assessment > For: dual diagnosis, second diagnosis > Non-Government Organisations > Anglicare > Uniting Communities > Relationships Australia > For: family and parent support, parenting programs

39 Referral / Support Options > Hearing > Hospital audiology > CYH Hearing Assessment Service > Can:Do Hearing > Private services

40 What else you can do > Refer for therapy when possible while waiting on appointment with CDU (or other service) > Address any factors that you can > Arrange interventions for parents if appropriate > Consider hearing assessment > If diet is poor, consider CBP, Fe Studies > Provide resources / information for parents

41 Take Home Points > Child behaviour issues are complex, with individual, family and societal factors influencing individual children in unique ways assessment and management take time! > Every child behaves the way they do for a reason > Developmental delays are common, and can present with behaviour issues similar to those seen in ADHD & ASD > Parenting and the home environment strongly contribute to child behaviour > Consider the possibility of attachment issues or exposure to trauma they can result in behaviour symptoms similar to those seen in ADHD and ASD

42 Resources For Parents > Raising Children Network: raisingchildren.net.au > Children with ASD & Disability app > Parenting SA: decd.sa.gov.au/parentingsa/ - Parent Easy Guides (PEGs) > Child and Youth Health: cyh.com > Zerotothree.org excellent factsheets for parents > Supernanny.co.uk > Sleephealthfoundation.org.au > Autism SA Infoline ( )

43 Resources - Professional > are/documents/red-flags-guide.pdf > Strengths and Difficulties Questionnaire: sdqinfo.com > Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT R/F): mchatscreen.com > Circle of Security: circleofsecurity.net handouts for parents

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