Behavioural Disorders in Children and Adolescents: Assessment, Emergency Management and Treatment

Focus: behavioural disorders in children and adolescents | Audience: emergency medicine, nursing, clinical medicine and allied-health students.

Learning objectives

• Define a behavioural problem and distinguish developmentally expected behaviour from a disorder.
• Recognise ADHD, oppositional defiant disorder (ODD), conduct disorder (CD), common habit/elimination problems and behaviour caused by medical, developmental, trauma or environmental conditions.
• Perform a safe, culturally sensitive assessment using the child, caregiver, school and community perspectives.
• Give a logical response from first contact and immediate safety through hospital care, psychosocial treatment, medication, nursing care, discharge and prevention.

1. What is a behavioural disorder?

Behaviour is the way a person acts, communicates and responds to people or situations. A behaviour is not automatically a disease: tantrums, fears, bed-wetting, thumb-sucking, sleep talking and separation distress can occur during normal development. A behavioural disorder is a persistent, recurrent pattern that is substantially outside developmental and cultural expectations and causes clinically important distress, injury, impaired learning, disturbed family or peer relationships, or loss of function.

The supplied paediatric seminar describes behavioural problems as a child’s difficulty adjusting to a complex environment and highlights faulty parental attitudes, inadequate family environment, illness/disability, social relationships, mass media and social change as influences. It also discusses emotional, physical and social deprivation, temper tantrums, breath-holding, sleep behaviours, enuresis, encopresis, pica, thumb-sucking and ADHD. These observations are useful starting points, but a modern assessment must also consider neurodevelopment, trauma, safeguarding, mental illness and medical causes.

2. Classification: a practical clinical map

3. Causes and risk factors

• Child factors: temperament, prematurity, genetic/neurodevelopmental vulnerability, language delay, sensory impairment, epilepsy, chronic pain, sleep loss, malnutrition, puberty, learning difficulty and traumatic brain injury.
• Family and attachment: inconsistent or harsh discipline, caregiver depression or substance use, domestic violence, parental separation, bereavement, overcrowding, neglect, rejection, excessive comparison and lack of predictable routines. Poverty is a risk context, not a parental diagnosis.
• School and peers: bullying, exclusion, academic failure, inaccessible teaching, peer pressure, discrimination and unsafe school environments.
• Trauma and safeguarding: physical, emotional or sexual abuse, exploitation, online grooming, forced migration and community violence may present as aggression, withdrawal, sexualised behaviour, enuresis, sleep disturbance or sudden decline in school performance.
• Media and environment: age-inappropriate violent content, uncontrolled digital use, sleep-disrupting devices and unsafe neighbourhood exposure can amplify symptoms, but media alone rarely explains a severe persistent disorder.
• Protective factors: a stable caring adult, safe school, early developmental support, adequate sleep and nutrition, meaningful play, positive peer relationships and access to health and social services.

4. Developmental normality versus disorder

Ask whether the behaviour is expected for age, culture and stage; whether it is transient; whether the child can stop with support; whether it occurs in more than one setting; and whether it produces harm or significant impairment. A behaviour that is common at age two may be concerning at age ten. Do not pathologise culturally accepted communication or gender expression.

5. First contact: a structured assessment

5.1 Engagement and history

1. Introduce yourself to the child and caregiver; explain confidentiality and its limits, especially when there is risk of harm or abuse.
2. Speak with the child in an age-appropriate way, then obtain caregiver and (with consent) teacher information. Adolescents need private time without the caregiver.
3. Use neutral language: “What happens before, during and after the episode?” rather than “Why are you naughty?”
4. Map onset, frequency, duration, severity, setting, triggers, early warning signs, consequences and what has helped or worsened it. Record an ABC chain: Antecedent → Behaviour → Consequence.
5. Ask about pregnancy, birth, milestones, language, school performance, friendships, family structure, routines, sleep, diet, toileting and previous services.
6. Screen for sadness, anxiety, irritability, mania, hallucinations, suicidal thoughts, self-harm, trauma, bullying, substance exposure and online risk.
7. Ask directly about violence at home, physical punishment, sexual contact, neglect and feeling unsafe. Believe disclosures, do not interrogate or promise secrecy.
8. Review every prescribed, over-the-counter and traditional medicine, caffeine/energy drinks and possible toxin exposure.

5.2 Examination and investigations

• Record vital signs, mental state, growth (height, weight, BMI), hydration, injuries, bruises, neurological signs, vision/hearing and pubertal status when relevant.
• Look for delirium: acute fluctuating attention, altered consciousness, disorientation, fever or abnormal vital signs. This is an emergency, not a primary behavioural diagnosis.
• Investigate selectively: glucose and electrolytes for altered consciousness or severe illness; toxicology only when clinically indicated and with consent/legal safeguards; pregnancy testing when relevant before medication; full blood count, thyroid tests, infection tests, EEG, neuroimaging or sleep study only for a specific indication.
• Do not use a questionnaire as a diagnosis. Validated tools (for example, Vanderbilt/Conners for ADHD or SDQ) support, but do not replace, a clinical assessment and collateral information.

6. Immediate emergency management

Acute agitation: attempt verbal de-escalation first. Check for delirium, hypoglycaemia, hypoxia, intoxication, withdrawal, psychosis, mania, autism-related sensory overload and pain. If medication is essential because of immediate danger, follow the hospital paediatric protocol and obtain senior review. Dose examples vary by age, weight and formulation; they are not prescriptions:

• Oral medication is preferred when cooperative. Some protocols use lorazepam 0.05–0.1 mg/kg (maximum 2 mg) or an antipsychotic such as olanzapine 0.1 mg/kg (maximum 5–10 mg) for severe agitation; monitor airway, breathing, blood pressure, sedation and dystonia.
• Avoid combining intramuscular olanzapine and parenteral benzodiazepines close together because of respiratory-depression risk; follow local policy.
• For a child with delirium or possible poisoning, obtain toxicology/paediatric advice before sedatives. Never use diazepam routinely for ordinary sleepwalking or as a behavioural punishment.

7. Core disorders and distinguishing features

7.1 Attention-deficit/hyperactivity disorder (ADHD)

ADHD is a neurodevelopmental disorder with developmentally inappropriate and persistent inattention and/or hyperactivity-impulsivity that causes impairment. The supplied seminar lists hyperactivity, impulsivity, disorganisation, inattention, distractibility and difficulty making/keeping friends. Modern diagnosis requires symptoms beginning in childhood, persisting over time, occurring in at least two settings, and not being better explained by anxiety, trauma, sleep disorder, learning/language difficulty, autism, depression, mania, epilepsy, substance use or an unsafe environment.

• Inattention: careless mistakes, poor sustained attention, seems not to listen, fails to finish, disorganisation, avoids prolonged mental effort, loses things and is easily distracted/forgetful.
• Hyperactivity/impulsivity: fidgeting, leaving seat, running/climbing when inappropriate, unable to play quietly, “on the go,” excessive talking, blurting answers, difficulty waiting and interrupting.
• Management: psychoeducation, parent training, classroom accommodations, predictable routines, exercise, sleep treatment and medication when impairment remains significant. Treat learning, anxiety, trauma, epilepsy and substance use concurrently.

7.2 Oppositional defiant disorder

ODD involves a persistent pattern of angry/irritable mood, argumentative/defiant behaviour or vindictiveness toward authority figures or close relationships. Assess whether the pattern is pervasive, intentional or a response to communication difficulty, trauma, inconsistent limits or ADHD. It must not be diagnosed solely because a child questions an unfair or unsafe demand.

7.3 Conduct disorder

CD is a repetitive pattern violating others’ basic rights or major age-appropriate rules: aggression or bullying, cruelty, weapon use, deliberate property destruction or fire-setting, theft/deceit, and serious rule violations such as truancy, running away or staying out despite prohibitions. Look for callous-unemotional traits, substance use, trauma, peer violence and safeguarding risk. Early, intensive family and multisystem intervention is important.

7.4 Common paediatric behavioural problems

• Temper tantrums: ensure safety, stay calm, remove audience/reinforcement, use few words, do not give the demanded item after aggression, and reconnect and teach emotion words after recovery. Frequent prolonged tantrums, injury, loss of consciousness or developmental regression require assessment.
• Breath-holding spells: cyanotic or pallid episodes may follow crying, pain or fright and usually self-resolve. Place the child safely on the side, do not shake or put objects in the mouth, assess for seizure/cardiac disease and check iron deficiency when recurrent. Refer urgent cases with exertion, prolonged unconsciousness, abnormal examination or family sudden-death history.
• Enuresis: distinguish primary from secondary; ask about constipation, UTI symptoms, diabetes, sleep, psychosocial stress and abuse. Avoid shame. Treat constipation/UTI, use a bladder diary, regular daytime toileting, evening fluid planning and positive rewards. Alarm therapy is effective; desmopressin may be prescribed for selected nocturnal enuresis with fluid restriction and counselling about hyponatraemia.
• Encopresis: most commonly relates to constipation with overflow. Examine gently, disimpact and maintain stool-softening treatment per paediatric protocol, regular toilet sitting and rewards. Do not punish or assume intentional soiling; assess developmental, emotional and safeguarding issues.
• Pica: persistent ingestion of non-food items requires assessment for iron deficiency, lead and other toxins, parasitic exposure, malnutrition, developmental disability and unsafe supervision. Remove hazards, correct deficiencies and provide behavioural and family support.
• Thumb-sucking/nail-biting: reassure when developmentally transient; avoid ridicule and punishment, identify stress, use competing activities and positive reinforcement. Persistent thumb-sucking may affect dentition; refer to dental care.
• Hair-pulling/skin-picking: examine for alopecia, wounds or infection; assess anxiety/OCD-spectrum symptoms and provide habit-reversal/CBT referral. Trichophagia with abdominal pain or vomiting may cause a bezoar.
• Sleep-linked behaviours: nightmares, sleepwalking, sleep talking, bruxism and insomnia may worsen daytime behaviour. Protect the environment, keep regular sleep/wake times, treat snoring/restless legs/pain and avoid frightening media. Recurrent injury, unusual movements or daytime sleepiness needs paediatric/sleep review.

8. Management aims and stepped plan

1. Keep the child, family, staff and community safe.
2. Identify and treat medical, developmental, trauma, family and school drivers.
3. Reduce frequency and severity while improving attachment, learning, sleep, relationships and participation.
4. Teach caregivers and the child practical skills that generalise across settings.
5. Use medication only when the diagnosis and indication are clear, with shared decision-making and monitoring.
6. Prevent recurrence, exclusion, institutionalisation, substance use and contact with the justice system.

9. Psychosocial and family treatment

9.1 Parent and caregiver interventions

• Give one or two clear, age-appropriate instructions; ask the child to repeat them; use immediate specific praise for cooperation.
• Set a small number of positively worded, consistent rules. Consequences should be brief, predictable, proportionate and non-violent.
• Use planned ignoring only for safe attention-seeking, never for danger, distress, pain or disclosure. Give time-in, co-regulation and repair after an episode.
• Use reward charts or token systems for observable behaviours; review daily and fade gradually. Never remove food, medication, school access or affection.
• Schedule daily positive play, exercise, reading and one-to-one attention; protect sleep and regular meals.

9.2 Child, school and family therapy

• CBT/problem-solving teaches emotion identification, coping, delay, perspective taking and repair.
• Trauma-focused therapy is indicated after trauma when the child is safe and able to engage; do not force disclosure.
• Family therapy addresses coercive cycles, communication, conflict and caregiver mental health.
• School plans may include a trusted adult, seating with fewer distractions, task chunking, movement breaks, visual schedules, positive behaviour support, anti-bullying action and a safe exit plan.
• For severe conduct problems, refer to multidisciplinary child and adolescent mental-health services and, where available, intensive family/community or multisystemic programmes.

10. Medication: indications, examples, contraindications and monitoring

11. Nursing and multidisciplinary interventions

1. Establish a therapeutic relationship; use the child’s preferred name, respectful language and culturally safe communication.
2. Complete and document risk assessment at admission, after any incident, after medication and before leave/discharge.
3. Maintain a calm, uncluttered, low-stimulation environment; keep exits visible, remove hazards and provide privacy while maintaining observation.
4. Observe triggers, early warning signs, sleep, food/fluid intake, toileting, medication effects and peer interactions; use an ABC chart.
5. Use de-escalation, sensory regulation, breathing, grounding, choices and a negotiated crisis plan. Call trained assistance early.
6. During restraint or seclusion, if legally permitted, use the least restrictive method, continuous airway/breathing/circulation observation, frequent release/reassessment and full incident documentation. Never prone-restrain a breathing-compromised child.
7. Administer medicines exactly as prescribed; check weight-based calculations, interactions, consent, allergies and response; monitor sedation, vitals, EPS, glucose and hydration as indicated.
8. Teach caregivers positive reinforcement, safe limit-setting, sleep hygiene, medication administration and warning signs; check understanding with teach-back.
9. Coordinate paediatrics, mental health, social work, school, occupational/speech therapy, dentistry, child protection and community services.
10. Arrange follow-up with a written crisis plan, emergency contacts, school plan, refill/monitoring dates and a clear route back to hospital.

12. Safeguarding and legal/ethical duties

• Behavioural change can be a sign of abuse, exploitation, trafficking, bullying or domestic violence. Explain mandatory-reporting duties according to Ugandan law and facility policy.
• Interview the child privately where safe; record the child’s own words in quotation marks, objective findings, dates, diagrams/photos according to policy, and who was present.
• Do not confront a suspected perpetrator, conduct repeated leading interviews or promise absolute secrecy. Ensure immediate protection and referral to the designated child-protection team.
• Respect assent, parental responsibility, confidentiality and the adolescent’s rights while acting when there is serious risk.

13. Discharge, prevention and follow-up

• Discharge only when immediate risk is controlled, a responsible caregiver is available, the environment is safe and follow-up is booked.
• Give written triggers, early warning signs, calming steps, medication schedule, crisis numbers and return precautions: escalating violence, self-harm thoughts, confusion, seizure, fever, intoxication, severe sedation or inability to keep the child safe.
• Prevent problems through responsive caregiving, non-violent discipline, early developmental and language screening, hearing/vision correction, school inclusion, anti-bullying programmes, trauma prevention, substance education, safe digital use and community support.
• Review progress using functional goals (attendance, sleep, injuries, relationships and learning), not merely whether a child is quiet. Adjust the plan with child and family feedback.

14. Worked clinical scenarios

15. Quick self-test

1. What features distinguish a behavioural disorder from a developmentally normal tantrum?
2. Why must ADHD symptoms be assessed across settings and against sleep, learning, trauma and medical differentials?
3. List the four CD domains: aggression, property destruction, deceit/theft and serious rule violation.
4. What are the first five actions for a dangerously agitated child?
5. Why is corporal punishment inappropriate and potentially harmful?
6. Name baseline and follow-up monitoring for a stimulant and for risperidone.
7. What findings require urgent safeguarding referral?

Key references and source note

This resource expands the supplied seminar, Behavioural disorders (Slideshare), which covers causes, deprivation-related problems, common paediatric behaviours and basic management. For clinical decisions, consult current WHO guidance, national Ugandan protocols, NICE guidance on conduct disorders and local child-protection law. Medication doses and emergency restraint policies must be checked against the child’s weight, formulation, comorbidities and facility protocol.