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Try out PMC Labs and tell us what you think. Learn More. Correspondence to: Dr. Mental health problems in children and adolescents include several types of emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive developmental autism disorders, characterized as either internalizing or externalizing problems. Disruptive behavioural problems such as temper tantrums, attention deficit hyperactivity disorder, oppositional, defiant or conduct disorders are the commonest behavioural problems in preschool and school age children.

DSM-5 and ICD are the universally accepted standard criteria for the classification of mental and behaviour disorders in childhood and adults. The age and gender prevalence estimation of various childhood behavioural disorders are variable and difficult to compare worldwide. A review of relevant published literature was conducted, including published meta-analyses and national guidelines. Childhood behaviour and emotional problems with their related disorders have ificant negative impacts on the individual, the family and the society.

They are commonly associated with poor academic, occupational, and psychosocial Naughty woman want sex Sugar Land. It is important for all healthcare professionals, especially the Paediatricians to be aware of the range of presentation, prevention and management of the common mental health problems in children and adolescents.

The routine Paediatric or General Practitioner clinic present with several desirable characteristics that make them ideal for providing effective mental health services to CYP. Childhood mental health disorders have ificant negative impacts on the individual, the family and the society.

It is particularly important for all Paediatricians to be aware of the range of presentation, prevention and management of the common mental health problems in CYP. Emotional problems, such as anxiety, depression and post-traumatic stress disorder PTSD tend to occur in later childhood. They are often difficult to be recognised early by the parents or other carers as many children have not developed appropriate vocabulary and comprehension to express their emotions intelligibly[ 5 ].

Many clinicians and carers also find it difficult to distinguish between developmentally normal emotions e. Emotional problems including disordered eating behaviour and low self-image are often associated with chronic medical disorders such as Naughty woman want sex Sugar Land dermatitis, obesity, diabetes and asthma, which lead to poor quality of life[ 7 - 9 ].

Various definitions for Naughty woman want sex Sugar Land wide range of childhood behavioural disorders are being used. The DSM-5[ 12 ] offers the commonest universally accepted standard criteria for the classification of mental and behaviour disorders.

The ICD is the alternative classification standard[ 13 ]. They can include self-injury, physical or verbal aggression, non-compliance, disruption of the environment, inappropriate vocalizations, and various stereotypies. These behaviours can impede learning, restrict access to Naughty woman want sex Sugar Land activities and social opportunities, and require a considerable amount of both manpower and financial resources to manage effectively.

Many instances of challenging behaviour can be interpreted as ineffective coping strategies for a young person, with or without learning disability LD or impaired social and communication skills, trying to control what is going on around them. Young people with various disabilities, including LD, Autism, and other acquired neuro-behavioural disorders such as brain damage and post-infectious phenomena, may also use challenging behaviour for specific purposes, for example, for sensory stimulation, gaining attention of carers, avoiding demands or to express their limited communication skills[ 15 ].

People who have a diverse range of neurodevelopmental disorders are more likely to develop challenging behaviours[ 16 ]. Some environmental factors have been identified which are likely to increase the risk of challenging behaviour, including places offering limited opportunities for making choices, social interaction or meaningful occupation. Other adverse environments are characterized by limited sensory input or excessive noise, unresponsive or unpredictable carers, predisposition to neglect and abuse, and where physical health needs and pain are not promptly identified.

Aggression is a common, yet complex, challenging behaviour, and a frequent indication for referral to child and adolescent Psychiatrists. Aggression has been linked to several risk factors, including individual temperaments; the effects of disturbed family dynamics; poor parenting practices; exposure to violence and the influence of attachment disorders. No single factor is sufficient to explain the development of aggressive behaviour[ 18 ].

Recent evidence suggests that DBPs should be regarded as a multidimensional phenotype rather than comprising distinct subgroups[ 20 ]. Children with CD often have trouble understanding how other people think, sometimes described as being callous-unemotional. They may falsely misinterpret the intentions of other people as being mean. They may have immature language skills, lack the appropriate social skills to establish and maintain friendships, which aggravates their feelings of sadness, frustration and anger[ 12 ].

CD is the commonest reason for CYP referral for psychological and psychiatric treatment. Majority of boys have an onset of CD before the age of 10 years, while girls tend to present mainly between 14 and 16 years of age[ 26 ]. Most CYP with CD grow out of this disorder, but a minority become more dissocial or aggressive and develop antisocial personality disorder as adults. They are mostly defiant towards authority figures, but they may also be hostile to their siblings or peers. This pattern of adversarial behaviour ificantly negatively impact on their lives at home, school, and wider society, and seriously impairs all their relationships[ 28 ].

Emotional problems in later childhood include panic disorder, generalized anxiety disorder GADseparation anxiety, social phobia, specific phobias, OCD and depression. Mild to moderate anxiety is a normal emotional response to many stressful life situations. Anxiety is regarded as a disorder when it is disproportionately excessive in severity in comparison to the gravity Naughty woman want sex Sugar Land the triggering circumstances, leading to abnormal disruption of daily routines.

Panic disorder is characterized by panic attacks untriggered by external stimuli. GAD is characterized by generalized worry across multiple life domains. Separation anxiety disorder is characterized by fear related to actual or anticipated separation from a caregiver. Social anxiety disorder also called social phobiais characterized by fear of social situations where peers may negatively evaluate the person[ 12 ].

Common manifestations of Anxiety disorders include physical symptoms such as increased heart rate, shortness of breath, sweating, trembling, shaking, chest pain, abdominal discomfort and nausea[ 29 ]. Other symptoms include worries about things before they happen, constant concerns about family, school, friends, or activities, repetitive, unwanted thoughts obsessions or actions compulsionsfears of embarrassment or making mistakes, low self-esteem and lack of self-confidence[ 30 ]. Depression often occurs in children under stress, experiencing loss, or having attentional, learning, conduct or anxiety disorders and other chronic physical ailments.

It also tends to run in families[ 7 - 931 ]. Disruptive mood dysregulation disorder DMDD is hood disorder characterized by a pervasively irritable or angry mood recently added to DSM The symptoms include frequent episodes of severe temper tantrums or aggression more than three episodes a week in combination with persistently negative mood between episodes, lasting for more than 12 mo in multiple settings, beginning after 6 years of age but before the child is 10 years old[ 32 ].

The definition of Autism has evolved over the years and has been broadened over time. Autism and Asperger Syndrome are the most widely recognised and clinically diagnosed among this group of disorders. CDD is a term used to describe children who have had a period of normal development for the first years before a relatively acute onset of regression and emergence of autistic symptoms. There are many intervention approaches and strategies, used alone or in combination, for supporting individuals with ASD.

These interventions need to individualized and be closely tailored to the level of social and linguistic abilities, cultural background, family resources, learning style and degree of communication skills[ 38 ]. Summary of common behavioural modification strategies for management of childhood emotional and behavioural disorder. Some authors consider that CYP Naughty woman want sex Sugar Land SCD present with similar but less severe restricted and repetitive interests and behaviours RRIBs characteristic of children on the autistic spectrum[ 41 ].

SCD is thought to occur more frequently in family members of individuals with autism[ 42 ]. The first randomized controlled trial of social communication interventions deed primarily for children with SCD was reported in [ 45 ]. PDA was first used in [ 46 ] for describing some CYP with autistic symptoms who showed some challenging behaviours. It is characterized by exceptional levels of demand avoidance requested by others, due to high anxiety levels when the individuals feel that they are losing control.

The outrageous acts and lack of concern for their behaviour appears to draw parallels with conduct problems CP and callous-unemotional traits CUTbut reward-based techniques, effective with CP and CUT, seem not to work in people with PDA[ 47 ]. Though demand avoidance is a common characteristic of CYP with ASD, it becomes pathological when the levels are disproportionately excessive, and normal daily activities and relationships are negatively impaired.

Unlike typically autistic children, people with PDA tend to have much better social communication and interaction skills, and are consequently able to use these abilities to their advantage. They often have highly developed social mimicry and role play, sometimes becoming different characters or personas.

They also often experience excessive mood swings and impulsivity. While the prevalence of ASD in boys is more than four times higher compared to that of girls, the risk of developing PDA appears to be the same for both boys and girls[ 47 ].

Accurate estimation of various childhood EBPs is difficult due to the problems of research methodologies relying on subjective assessments and varying definitions used. However, poverty and low socioeconomic status are risk factors that appear to increase the rate of MHDs across populations[ 49 ]. Reported prevalence rates for DMDD range from 0. The exact causes of various childhood EBPs are unknown. Several studies have identified various combinations of genetic predisposition and adverse environmental factors that increase the risk of developing any of these disorders.

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These include perinatal, maternal, family, parenting, socio-economic and personal risk factors[ 53 ]. Summary of common risk factors for development of childhood emotional and behavioural disorder. Anxiety seems to be transmissible from mothers to their preschool children, through both genetic factors and also through behaviour modelling and an anxious style of parenting[ 6 ]. A developmental taxonomy theory has been proposed by Patterson et al[ 75 ] to help understand the mechanisms underlying early onset and course of CPs. They described the vicious cycle of non-contingent parental responses to both prosocial and antisocial child behaviour leading to the inadvertent reinforcement of child behaviour problems.

This adverse child behavioural training combined with social rejection often lead to deviant peer affiliation and delinquency in adolescence[ 76 ].

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The most consistently reported structural abnormalities associated with the DBD include reduced grey matter volume GMV in the amygdala, frontal cortex, temporal lobes, and the anterior insula, which is involved in part of a network related to empathic concern for others. Reduced GMV along the superior temporal sulcus has also been found, particularly in girls[ 77 ]. A decreased overall mean cortical thickness, thinning of the cingulate and prefrontal cortices; and decreased grey matter density in different brain regions have been reported[ 78 ].

Subtle neurobiological changes in different parts of the brain of CYP with EBPs have been reported from many research studies of functional scans. Peculiar brain changes have been found in the hypothalamus, inferior and superior parietal lobes, right amygdala and anterior insula[ 79 ]. Functional MRI studies have demonstrated less activation in the temporal cortex in violent adult offenders[ 80 ] and in antisocial and psychopathic individuals[ 81 ] compared to non-aggressive offenders. It has been hypothesized that high levels of prenatal testosterone exposure appears to be part of the complex aetiology of EBDs, providing possible explanation for the higher prevalence in males for DBDs, by increasing susceptibility to toxic perinatal environments such as exposure to maternal nicotine and alcohol in pregnancy[ 83 ].

CD has been linked to failure to complete schooling, attaining poor school achievement, poor interpersonal relationships, particularly family breakup and divorce, and experience of long-term unemployment. DBPs in parents have been linked to the abuse of their offspring, thereby increasing their risk of developing CD[ 8485 ]. Children presenting with hyperactivity-inattention behaviours are more likely to have a more favourable educational outcome compared with those with aggression or oppositional behaviours[ 8687 ]. A high prevalence of sleep disturbances is associated with various childhood EBPs.

Sleep problems in early childhood is associated with increased prevalence of later Anxiety disorders and ODD[ 8889 ]. Several studies have confirmed a strong relationship between early childhood EBPs and poor future long-term physical and mental health outcomes. Individuals on the adolescent-onset CP path often consume more tobacco and illegal drugs and engage more often in risky sexual behaviour, self-harm, and have increased risk of PTSD, than individuals without childhood conduct problems.

They also frequently experience parenting difficulties, including over-reactivity, lax and inconsistent discipline, child physical punishment and lower levels of parental warmth and sensitivity[ 74849394 ]. Other potential complications include adverse mental and physical health outcomes, social justice system involvement including incarceration, substance use and abuse, alcoholism, homelessness, poverty and domestic abuse[ 9596 ]. An analysis of several Scandinavian studies up to the s has shown higher rates of violent death, estimated to be almost five times higher than expected among young people with Naughty woman want sex Sugar Land, with common associated predictive factors including behavioural problems, school problems, and co-morbid alcohol or drug abuse and criminality[ 97 ].

This should include general medical, developmental, family, social, educational and emotional history. Physical and neurological examination should include assessment of vision, hearing, dysmorphic features, neuro-cutaneous stigmata, motor skills and cognitive assessment. Condition-specific and generic observer feedback on screening rating scales and questionnaires can be used to complement direct clinical observations. There is no single gold-standard diagnostic tool available for the diagnosis of EBDs, which largely depends on the clinical skills of an integrated collaboration of multi-professional experts.

Diagnosis relies on interpretation of subjective multi-source feedback from parents or carers, teachers, peers, professional or other observers provided through a of psychometric questionnaires or screening tools[ 98 ]. ificant discrepancies between various respondents are quite common and clinical diagnosis cannot rely on the psychometric tools alone.

There is evidence from the literature suggesting that parents have Naughty woman want sex Sugar Land tendency to over-report symptoms of ODD and CD in children compared to the teachers[ 99 ]. The tools help to identify which Naughty woman want sex Sugar Land would require more in-depth clinical interventions[ ].

Supplement material shows a list of common Mental Health screening and assessment tools, summarizing their psychometric testing properties, cultural considerations and costs. It requires multi-level and multi-disciplinarian approaches that include professionals such as Psychologists, Psychiatrists, Behavioural Analysts, Nurses, Social care staff, Speech and language Therapists, Educational staff, Occupational Therapists, Physiotherapists, Paediatricians and Pharmacists.

Use of pharmacotherapy is usually considered only in combination with psychological and other environmental interventions[ 15 ]. Holistic management strategies will include various combinations of several interventions such as child- and family-focused psychological strategies including Cognitive Behavioural Therapy CBTbehavioural modification and social communication enhancement techniques, parenting skills training and psychopharmacology. These strategies can play ificant roles in the management of children with a wide range of emotional, behavioural and social communication disorders.

Effective alternative educational procedures also need to be implemented for the school age children and adolescents. In early childhood, similar parenting strategies have been found useful to manage several apparently dissimilar EBPs e. This may suggest there is a common maintaining mechanism, which is probably related to poor self-regulation skills, involving the ability to control impulses and expressions of emotion[ ].

Several studies have confirmed the effectiveness of various psychological and pharmacologic therapies in the management of childhood EBDs. A meta-analysis of thirty-six controlled trials, involving children mean sample age, 4. The mainstay of management for CDs includes individual behavioural or cognitive therapy, psychotherapy, family therapy and medications[ ]. Any challenging behaviour from CYP is likely to elicit persistent negative reactions from many parents, using ineffective controlling strategies and a decrease in positive responses[ ].

There is evidence from published research that social-learning and behaviourally based parent training is capable of producing lasting improvement in children with callous-unemotional traits or CD, reducing externalizing problems for children with DBDs, leading to ificant parent satisfaction, particularly when delivered early in childhood[ 84- ]. These interventions are typically delivered in a group format, one 2-h session per week Naughty woman want sex Sugar Land wk, by trained leaders, with the focus on improving parenting skills to manage child behaviour, where parents typically learn to identify, define and observe problem behaviours in new ways, as well as learn strategies to prevent and respond to oppositional behaviour[].

Pooled estimates from a review of 37 randomised controlled studies identified a statistically ificant improvement on several rating scales among children with CD up to the age of 18 years[ 23 ]. A meta-analysis of 24 studies confirmed that Parent-Child Interaction Therapy PCIT demonstrated ificantly larger effect sizes for reducing negative parent behaviours, negative child behaviours, and caregiver reports of child behaviour problems than did most or all forms of Positive Parenting Programme Triple P [ ]. A recent Cochrane review of 13 studies confirmed the efficacy and cost-effectiveness of group-based parenting interventions for alleviating child conduct problems, enhancing parental mental health and parenting skills, at least in the short term[ ].

Research has focused on identifying alternative educational strategies that can be used to improve learning opportunities for children presenting with challenging behaviours from various causes.

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Supportive school strategies for children with EBDs have traditionally focused on classroom management, social skills and anger management, but many researchers have more recently argued that academically-focused interventions may be most effective[ ].

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