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Mental Health & Substance Use

Childhood Behavioural Disorders

A group of disorders characterized by persistent patterns of behaviour in children or adolescents that deviate significantly from age-appropriate norms and cause impairment in social, academic, or occupational functioning. Includes ADHD and disruptive behaviour disorders.

Also known as: Conduct Disorder, Oppositional Defiant Disorder (ODD), Attention Deficit Hyperactivity Disorder (ADHD), Disruptive Behaviour Disorders

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Referral and warning signs

When to refer

Refer to specialist (Child Psychiatrist/Psychologist, Pediatrician with expertise - HC4/H/RR) if: Severe or complex behavioural problems. Failure to respond to initial non-pharmacological interventions. Consideration for medication (ADHD). Suspicion of co-occurring disorders (learning disability, anxiety, depression, developmental disorder). Significant family dysfunction requiring specialized therapy.

Red flags

  • Aggression causing serious harm to self or others
  • Cruelty to animals
  • Fire-setting
  • Persistent serious violation of rules (truancy, running away)
  • Suicidal ideation or self-harm
  • Symptoms suggestive of psychosis
  • Suspicion of abuse or neglect as underlying cause

Signs and symptoms

  • Attention Deficit Hyperactivity Disorder (ADHD):
  • - Inattention: Difficulty sustaining attention, easily distracted, doesn't seem to listen, fails to finish tasks, loses things, forgetful, avoids tasks requiring sustained mental effort.
  • - Hyperactivity: Fidgeting, unable to stay seated, running/climbing excessively, difficulty playing quietly, often 'on the go'.
  • - Impulsivity: Blurting out answers, difficulty waiting turn, interrupting others.
  • - Symptoms must be present before age 6-12 (depending on criteria), occur in multiple settings (home, school), persist >6 months, and cause significant impairment.
  • Other Behavioural Disorders (e.g., Conduct Disorder, ODD):
  • - Oppositional/Defiant Behaviour: Argumentative, defiant towards authority figures, deliberately annoys others, blames others, easily annoyed, angry/resentful (ODD).
  • - Aggressive Conduct: Bullying, physical fights, cruelty to people or animals, using weapons.
  • - Destruction of Property: Fire-setting, vandalism.
  • - Deceitfulness or Theft: Lying, stealing, conning others.
  • - Serious Violation of Rules: Staying out late, running away from home, truancy from school (Conduct Disorder).
  • - Frequent/Severe Temper Tantrums (beyond what's typical for age).
  • IMPORTANT: Differentiate from normal childhood behaviour/mischief and reactions to specific stressors (abuse, neglect, bullying).

Risk factors

  • Genetic/Biological factors.
  • Family factors (parental mental illness/substance use, harsh/inconsistent discipline, family conflict, abuse/neglect).
  • Social/Environmental factors (poverty, community violence, peer rejection).
  • Co-occurring conditions (learning disabilities, depression, anxiety, developmental disorders).

Diagnosis

Clinical assessment

Diagnosis based on detailed history from parents/caregivers and teachers regarding specific behaviours, frequency, duration, settings, and degree of impairment. Direct observation of child's behaviour. Use standardized rating scales (e.g., Vanderbilt, Conners') if available. Rule out underlying medical conditions (e.g., hyperthyroidism, sensory impairments, lead poisoning), other mental health disorders (depression, anxiety, psychosis), epilepsy, and developmental disorders. Crucially distinguish from normal behaviour or reaction to trauma/fear.

Investigations

  • Clinical assessment is primary.
  • Hearing and vision screening.
  • Consider investigations for underlying medical conditions if suspected.
  • Psychoeducational testing if learning disability suspected.

Diagnostic criteria

Based on diagnostic criteria (e.g., DSM-5, ICD) for specific disorders (ADHD, ODD, Conduct Disorder), requiring a pattern of behaviour meeting threshold for frequency, duration, and causing significant impairment.

Management

Non-pharmacological management

  • FIRST LINE approach:
  • - Psychoeducation: Educate family/caregivers and teachers about the disorder and management strategies.
  • - Parent Management Training (PMT): Teach parents effective techniques for managing behaviour (positive reinforcement, setting clear rules/consequences, structured routines).
  • - School-Based Interventions: Collaborate with teachers for classroom management strategies, accommodations (e.g., preferential seating), support for learning difficulties.
  • - Behavioural Therapy for the child (e.g., social skills training, problem-solving skills).
  • - Family Therapy: Address family conflicts and communication.
  • - Address Underlying Stressors: If behaviour is a reaction to trauma, abuse, or bullying, ensure child's safety and address the stressor directly (this is NOT a behavioural disorder in that case).

Pharmacological treatment

  • Medication considered ONLY for moderate-severe ADHD unresponsive to adequate trial of non-pharmacological interventions, under specialist supervision.
  • - Stimulants: Methylphenidate (Ritalin) is first-line for ADHD. Requires careful titration and monitoring for side effects (decreased appetite, insomnia, headache, stomach ache, potential impact on growth, tics). (RR level supervision).
  • - Non-Stimulants (e.g., Atomoxetine): Alternative for ADHD if stimulants ineffective or not tolerated (Specialist level).
  • Medication generally NOT first-line for ODD/Conduct Disorder, but may be used to treat co-occurring ADHD or aggression (e.g., antipsychotics like Risperidone used cautiously for severe aggression - Specialist).
  • Follow specific Ugandan treatment algorithms/guidelines.

Monitoring

Monitor target behaviours, academic performance, social functioning. Monitor adherence to behavioural strategies and medication (if used). Monitor for medication side effects (appetite, sleep, mood, vital signs, growth). Regular communication between parents, teachers, and healthcare providers.

Complications

  • Poor academic achievement, school dropout
  • Difficulties with peer relationships, social isolation
  • Family conflict
  • Increased risk of injuries
  • Development of substance use disorders later in life
  • Development of antisocial personality disorder (from Conduct Disorder)
  • Co-occurring anxiety, depression

Prevention

  • Early intervention programs for at-risk families.
  • Parenting skills training.
  • School-based programs promoting social-emotional learning.
  • Addressing underlying social determinants (poverty, violence).

Patient education

  • Educate parents/caregivers about the specific disorder, its causes (multifactorial), and treatment approaches.
  • Emphasize the importance of consistency in behavioural strategies across settings (home, school).
  • Explain the rationale, benefits, and potential side effects if medication is considered.
  • Provide realistic expectations about treatment outcomes.
  • Encourage positive parenting practices.
  • Provide information on support resources.

Uganda-specific notes

Behavioural disorders in children may be under-recognized or misattributed. Differentiate from effects of trauma, harsh discipline, or lack of stimulating environment. Access to specialist assessment, psychoeducational testing, and specific therapies (PMT, CBT) is very limited. Methylphenidate availability is restricted. Focus on psychoeducation, parenting support, and school collaboration.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 9, Section 9.2.7 (Note: UCG text incorrectly labels this 9.1.3, but content aligns with Childhood Behavioural Disorders)

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