Behavioural and Developmental Issues in Children

Last updated 1 Jun 2026 · Paediatrics / Child Psychiatry

📋 Key Information Summary

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Temperament is an innate neurobiological trait; recognising temperament types (easy, slow-to-warm, difficult) guides anticipatory parenting advice and reduces misinterpretation of normal variation as pathology.
Behavioural management in early childhood centres on positive reinforcement, consistent limit-setting, and planned ignoring; parent-training programmes (e.g., Triple P, Circle of Security) are first-line for disruptive behaviours.
Intellectual disability (ID) is defined by IQ <70 with concurrent deficits in adaptive functioning, presenting before age 18 years; aetiology is genetic in ~40% of cases — chromosomal microarray and fragile X testing are first-line investigations.
Cerebral palsy (CP) affects ~2 per 1,000 live births in Australia; diagnosis is primarily clinical (abnormal tone, posture, movement) supported by MRI brain; the GMFCS guides functional classification and intervention planning.
Autism spectrum disorder (ASD) prevalence is approximately 1 in 70 Australian children; early identification (18-month developmental checks) and early intensive behavioural intervention (EIBI) before age 4 years yield the best outcomes.
ADHD affects ~7–8% of Australian school-age children; diagnosis requires ≥6 inattentive and/or hyperactive-impulsive symptoms (DSM-5-TR) in two settings for ≥6 months; methylphenidate is first-line pharmacotherapy.
Breath-holding attacks (cyanotic and pallid types) are benign, reflexive episodes peaking at age 2 years; parental reassurance and iron supplementation (if ferritin <30 µg/L) are key management strategies.
Red flags warranting urgent referral include: loss of previously acquired developmental milestones (regression), persistent hand-flapping/lining up of objects beyond 24 months, focal neurological signs, and severe self-injurious behaviour.
Multi-disciplinary care is essential — speech pathologists, occupational therapists, psychologists, paediatricians, and allied health assistants coordinate through NDIS and Medicare-funded plans (GP Management Plan, Team Care Arrangement).
Aboriginal and Torres Strait Islander children have higher rates of developmental vulnerability (AEDC); culturally safe assessment, family-centred practice, and connection to community-controlled health services are mandatory.

Introduction & Australian Epidemiology

Behavioural and developmental disorders represent one of the most common reasons for paediatric consultation in Australian general practice. These conditions span a broad spectrum — from normal temperamental variation and benign behavioural phenomena (such as breath-holding attacks) through to neurodevelopmental disabilities (intellectual disability, cerebral palsy, autism spectrum disorder, ADHD) that require lifelong, co-ordinated, multidisciplinary care.

The Australian Early Development Census (AEDC) 2021 reported that approximately 22% of Australian children entering school show developmental vulnerability in one or more domains, with rates significantly higher in remote and very remote areas. The National Disability Insurance Scheme (NDIS) supports >250,000 children aged 0–14 years, with autism spectrum disorder and intellectual disability among the leading primary disability types.

General practitioners (GPs) are the first point of contact for most families and play a critical role in surveillance, early identification, initial management, and co-ordinated referral. The RACGP's Guidelines for Preventive Activities in General Practice (Red Book, 9th edition) and the Royal Australasian College of Physicians (RACP) recommend structured developmental surveillance at key ages: the newborn check, 6 weeks, 4 months, 6 months, 12 months, 18 months, 2 years, and 4 years (pre-school).

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Key surveillance windows: The 12-month, 18-month, and 30-month well-child visits are critical for identifying early signs of autism spectrum disorder and language delay. The Modified Checklist for Autism in Toddlers (M-CHAT-R/F) should be administered at 18 months.

Australian Burden of Disease

Condition	Estimated Prevalence (Australia)	Peak Age of Identification	Key Risk Factors
ADHD	7–8% of school-age children	6–12 years	Family history, prematurity, low birth weight
Autism Spectrum Disorder	~1 in 70 (rising with improved detection)	2–5 years	Male sex (4:1), family history, advanced parental age
Intellectual Disability	1–3%	Variable; often <5 years	Genetic syndromes, prenatal alcohol, extreme prematurity
Cerebral Palsy	~2 per 1,000 live births	12–24 months	Prematurity, birth asphyxia, neonatal stroke
Breath-Holding Attacks	Up to 5% of children	6 months – 6 years (peak 2 years)	Iron deficiency, family history, temperamental reactivity

Temperament & Child Behaviour / Discipline

Understanding Temperament

Temperament refers to constitutionally based, biologically rooted differences in reactivity and self-regulation that emerge in infancy. The Thomas and Chess model classifies temperament into three primary types:

Easy temperament (~40%): Regular routines, positive approach to new situations, adaptable, mild-to-moderate intensity reactions.
Slow-to-warm temperament (~15%): Low activity level, withdrawal from novel stimuli, slow adaptation, generally mild reactions but with negative mood.
Difficult temperament (~10%): Irregular biological rhythms, intense emotional reactions, negative withdrawal from novelty, slow adaptability.
Mixed temperament (~35%): Characteristics that do not fit neatly into a single category.

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Goodness of fit: Behavioural difficulties often arise when there is a mismatch between the child's temperament and the expectations or demands of the environment (Thomas & Chess, 1977). Anticipatory guidance should focus on adapting the environment to the child's temperament rather than trying to change the child.

Common Behavioural Concerns

Tantrums and Oppositional Behaviour

Temper tantrums are a normal developmental phenomenon, peaking between 2–3 years. They represent frustration when verbal skills cannot keep up with emotional experience. Assessment should focus on frequency, duration, triggers, and whether the child can self-soothe after an episode.

When to refer: Tantrums persisting >25 minutes on average, occurring >5 times per day, involving self-injury or aggression beyond age 4, or associated with functional impairment at home/school warrant referral to a paediatrician or child psychologist.

Evidence-Based Parenting Programmes (Australian Context)

Programme	Age Group	Format	Key Evidence	Availability in Australia
Triple P (Positive Parenting Programme)	0–16 years	Group / individual / online	Level 1A RCT evidence; reduces disruptive behaviours by 30–50%	Widely available; state government funding
Circle of Security	0–5 years	Group (8 sessions)	Improves attachment security; RCT evidence	Nationwide; Medicare-funded via child health services
Incredible Years	3–8 years	Group (12–14 sessions)	Reduces conduct problems; Cochrane review supports efficacy	Available in most state child and family services
Parent-Child Interaction Therapy (PCIT)	2–7 years	Individual (coached live)	Gold-standard for disruptive behaviour; strong effect sizes	Limited; primarily tertiary paediatric psychology services

Principles of Effective Discipline

Positive Reinforcement

Praise desired behaviours immediately and specifically (ratio ≥5:1 positive to corrective statements).

Consistent Boundaries

Clear, age-appropriate rules with predictable consequences; both caregivers must be aligned.

Planned Ignoring

Withhold attention from minor disruptive behaviours while maintaining safety monitoring.

Time-Out (Brief)

1 minute per year of age in a boring, safe space; use for aggression or non-compliance after warning.

Emotion Coaching

Label the emotion, validate the feeling, set the limit on behaviour ("It's OK to be angry, it's not OK to hit").

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Physical punishment: The Australian Paediatric Association, RACP, and RACGP oppose physical punishment of children. It is associated with increased aggression, antisocial behaviour, and poorer mental health outcomes (Gershoff, 2002; Durrant & Ensom, 2012). Physical punishment of children is legislated as illegal in several Australian jurisdictions.

Intellectual Disability

Definition and Classification

Intellectual disability (ID) is characterised by significant limitations in both intellectual functioning (IQ <70) and adaptive behaviour (conceptual, social, and practical skills), with onset before age 18 years (DSM-5-TR; AAIDD). Severity is classified as:

Mild (IQ 50–70)

~85% of cases

May not be identified until school entry; academic difficulties; can achieve functional independence with support.

Setting: mainstream school with learning support

Moderate (IQ 35–49)

~10% of cases

Identified in preschool years; limited academic progress; requires ongoing supervision for independent living.

Setting: specialist school or supported mainstream

Severe/Profound (IQ <35)

~5% of cases

Identified in infancy; significant motor/language delays; requires comprehensive lifelong care.

Setting: specialist disability services / NDIS plan-managed

Aetiology

Genetic (~40%): Chromosomal abnormalities (Down syndrome, trisomy 18), single-gene disorders (fragile X syndrome — most common inherited cause, tuberous sclerosis, Rett syndrome), copy number variants (CNVs).
Prenatal (~20%): Foetal alcohol spectrum disorder (FASD) — the most common preventable cause in Australia, congenital infections (CMV, rubella, toxoplasmosis), maternal substance use.
Perinatal (~10%): Extreme prematurity (<28 weeks), birth asphyxia, neonatal hypoglycaemia, kernicterus.
Postnatal (~5%): Traumatic brain injury, meningitis/encephalitis, near-drowning, non-accidental injury.
Unknown (~25%): Despite advances in genomic testing, a significant proportion remain without a confirmed aetiology.

Investigations — Tiered Approach

Essential Chromosomal microarray (CMA) First-line genetic test; detects CNVs in 15–20% of cases. MBS item 73288 (Medicare-funded when ordered by specialist).

Essential Fragile X DNA testing (FMR1 CGG repeat) All boys with unexplained ID; consider in girls with features. Detects fragile X syndrome in 2–5% of males with ID.

Available Karyotype (if CMA negative + dysmorphic features) Detects balanced translocations and sex chromosome aneuploidies missed by CMA.

Available Whole exome sequencing (WES) Consider when CMA and fragile X negative; diagnostic yield 25–40%. Available through Victorian Clinical Genetics Services and other state services.

Available MRI brain If motor signs, microcephaly, or macrocephaly present; may reveal malformations, periventricular leukomalacia, or cortical dysplasia.

Available Thyroid function, lead level, metabolic screen To exclude treatable causes; serum ferritin (iron deficiency associated with developmental delay).

Referral Clinical genetics assessment For dysmorphic features, family history of ID, suspected syndromic aetiology.

Management

Management is multi-modal and lifelong. There is no single medication that treats intellectual disability; the focus is on maximising functional capacity, treating comorbidities (epilepsy in 20–30%, behavioural concerns in 30–50%, sensory impairment), and supporting families.

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Melatonin

Circadin® · Generic · Melatonin receptor agonist

Indication Sleep disturbance (very common in ID)

Paediatric dose 2–3 mg PO at bedtime (30 min before); titrate to 5–10 mg if needed. Use modified-release (Circadin) if difficulty with sleep onset and maintenance.

Renal adjustment Not required

PBS status ⚕ Authority Required (Circadin ≥55 yr); melatonin IR often private script

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Risperidone

Risperdal® · Atypical antipsychotic

Indication Irritability and severe behavioural disturbance in ID/ASD (when non-pharmacological strategies exhausted)

Paediatric dose 0.25 mg PO BD, titrate by 0.25 mg every 2 weeks; typical range 0.5–2 mg/day in divided doses

Key monitoring Weight, waist circumference, fasting glucose, lipids, prolactin at baseline and 3-monthly; ECG if dose >1 mg/day

PBS status 🔒 Authority Required — autism/ID-related irritability (paediatric specialist initiation)

Australian Disability Support

NDIS: Children with significant, permanent disability (including ID) may access NDIS Early Childhood Early Intervention (ECEI) pathway from birth to 6 years, then standard NDIS planning from age 7.
Medicare-funded plans: GP Management Plan (MBS item 721) and Team Care Arrangement (MBS item 723) enable rebates for up to 5 allied health services per calendar year.
Carer Allowance and Carer Payment: Available through Services Australia for families providing daily care.

Cerebral Palsy

Definition

Cerebral palsy (CP) describes a group of permanent disorders of movement and posture causing activity limitation, attributed to non-progressive disturbances that occurred in the developing foetal or infant brain (Rosenbaum et al., 2007). It is the most common physical disability in childhood in Australia.

Classification

Motor Type	Proportion	Key Features
Spastic (unilateral — hemiplegia)	~35%	Increased tone, clonus, upper motor neuron signs; affected side is smaller; hand preference before 12 months is a red flag
Spastic (bilateral — diplegia/quadriplegia)	~40%	Lower limb predominant (diplegia) or all four limbs (quadriplegia); scissoring gait; associated with prematurity
Dyskinetic (dystonia/choreoathetosis)	~15%	Fluctuating tone, involuntary movements; often term birth with hypoxic-ischaemic encephalopathy; intelligence frequently preserved
Ataxic	~5%	Low tone, wide-based gait, intention tremor, dysmetria; cerebellar origin
Mixed	~5%	Combination of the above patterns

Gross Motor Function Classification System (GMFCS)

GMFCS I

Walks without limitations

Can perform gross motor skills (running, jumping) with some difficulty in speed, balance, and coordination.

Mainstream school; community sport

GMFCS II

Walks with limitations

Walks independently; difficulty with long distances, stairs, uneven terrain; may use walking aid outdoors.

Mainstream school; modified PE

GMFCS III

Walks with assistive device

Requires hand-held mobility aid (crutches, walker); uses wheelchair for long distances; may use wheelchair in community.

Mainstream or supported school; accessibility modifications

GMFCS IV

Self-mobility with limitations

Powered mobility or manual wheelchair with assistance; some weight-bearing may be possible with support.

Modified environment; full accessibility required

GMFCS V

Transported in manual wheelchair

No independent mobility; significant postural support needs; high risk of hip subluxation, scoliosis, respiratory compromise.

Specialist or supported setting; full-time care

Early Red Flags (before definitive diagnosis)

Persistent fisting of the hand beyond 3 months of age
Asymmetry of movement or hand preference before 12 months
Persistent primitive reflexes (Moro, ATNR) beyond 6 months
Inability to sit independently by 9 months (corrected for prematurity)
Persistent head lag on pull-to-sit beyond 4 months
Feeding difficulties with poor suck-swallow coordination

Key Investigations

Essential MRI brain Abnormal in ~85% of cases; periventricular leukomalacia (preterm), cortical infarction, malformations. Best performed at term-equivalent age or after 2 years for white matter myelination.

Available Gross Motor Function Measure (GMFM-88) Standardised motor assessment; used for baseline and longitudinal monitoring of intervention effectiveness.

Available Hip surveillance X-rays AP pelvis at diagnosis, then 6-monthly until age 5 (GMFCS III–V), annually until skeletal maturity. CP hip displacement affects ~35% of GMFCS V children.

Available Swallowing assessment (videofluoroscopy / FEES) For all children with CP and feeding difficulties; aspiration risk is high.

Referral Neurophysiology (EEG) If suspected coexistent epilepsy (occurs in ~35–50% of CP).

Management of Spasticity

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Botulinum toxin A (Botox® / Dysport®)

Botox® · Dysport® · Neurotoxin

Indication Focal spasticity; improving gait, upper limb function, and ease of care

Dose Botox: 6–8 U/kg/session (max 200 U); Dysport: 10–20 U/kg/session (max 1,000 U); target muscles under US guidance

Frequency Every 12–16 weeks (minimum 12-week interval)

PBS status ✔ PBS General Benefit (for registered indications)

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Baclofen

Lioresal® · Generic · GABA-B agonist

Indication Generalised spasticity; oral for mild–moderate; intrathecal pump (ITB) for severe/refractory

Paediatric dose (oral) Start 2.5 mg PO BD–TDS (children <8 yr); 5 mg PO BD–TDS (≥8 yr); titrate by 5 mg every 3–5 days; max 2 mg/kg/day

Key adverse effects Drowsiness, drooling, weakness, seizures (paradoxical); withdrawal syndrome (do not stop abruptly)

PBS status ✔ PBS General Benefit

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Hip surveillance is mandatory: The Australian Cerebral Palsy Register recommends routine hip surveillance for all children with CP (GMFCS III–V are highest risk). Delayed detection of hip subluxation leads to painful dislocation requiring surgical intervention. Follow the Australian Hip Surveillance Guidelines (Wynter et al., 2011).

Autism Spectrum Disorder (ASD)

Definition and Diagnostic Criteria

Autism spectrum disorder is a neurodevelopmental condition characterised by persistent deficits in social communication and social interaction, plus restricted, repetitive patterns of behaviour, interests, or activities (DSM-5-TR, APA 2022). Symptoms must be present in the early developmental period (though they may not fully manifest until social demands exceed capacity) and cause functional impairment.

DSM-5-TR Diagnostic Criteria (Simplified)

Domain A — Social Communication

Deficits in social-emotional reciprocity (e.g., abnormal social approach, failure of normal back-and-forth conversation)
Deficits in non-verbal communicative behaviours (e.g., poor eye contact, absent gesture, lack of facial expression)
Deficits in developing and maintaining relationships (e.g., difficulty adjusting behaviour to context, absence of interest in peers)

Domain B — Restricted/Repetitive Behaviour

Stereotyped or repetitive motor movements, use of objects, or speech (lining up toys, echolalia, idiosyncratic phrases)
Insistence on sameness, inflexible adherence to routines
Highly restricted, fixated interests (abnormal in intensity or focus)
Hyper- or hypo-reactivity to sensory input (pain indifference, adverse response to sounds/textures)

Early Identification — Red Flags

By 12 months: No babbling, no pointing or gesturing, no response to name
By 16 months: No single words
By 24 months: No meaningful two-word phrases, any loss of language or social skills (regression)
Any age: Loss of any skills, persistent absence of joint attention (showing, sharing, pointing), no pretend play by 30 months

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Regression is a medical emergency in developmental terms: Any child who loses previously acquired language or social skills requires urgent assessment by a paediatrician. Regression after age 2 years raises concern for ASD but also for childhood disintegrative disorder, Landau-Kleffner syndrome, or neurodegenerative conditions.

Assessment Pathway in Australia

GP Surveillance

Administer M-CHAT-R/F at 18-month check; administer Parents' Evaluation of Developmental Status (PEDS) at all well-child visits.

Referral to Paediatrician / Child Psychiatrist

If screening positive or clinical concern; paediatrician will undertake structured developmental assessment.

Multidisciplinary Diagnostic Assessment

Gold standard: ADOS-2 (Autism Diagnostic Observation Schedule) + ADI-R (Autism Diagnostic Interview-Revised) + clinical assessment by paediatrician, psychologist, speech pathologist.

Post-Diagnostic Support

NDIS application, early intervention referral, parent education, school liaison, genetic testing (CMA + fragile X as per ID workup).

Evidence-Based Interventions

Intervention	Age Group	Evidence Level	Description
Early Intensive Behavioural Intervention (EIBI)	2–5 years	Level 1A (multiple RCTs)	20–40 hours/week of applied behaviour analysis (ABA)-based therapy; most effective when started before age 4
Speech-Language Pathology	All ages	Level 2	Augmentative and alternative communication (AAC) if non-verbal; social communication intervention; NDIS-funded
Occupational Therapy (Sensory Integration)	All ages	Level 2–3	Sensory processing, fine motor, activities of daily living; OT-led desensitisation for feeding aversion
Social Skills Group Training	School-age (5–16 yr)	Level 1B	Programmes such as Secret Agent Society (developed in Australia); improves emotion recognition and social skills
Structured Teaching (TEACCH)	All ages	Level 2	Visual schedules, structured environment, predictability; strengths-based approach

Pharmacotherapy for Comorbidities

There is no medication that treats the core features of ASD. Pharmacotherapy targets comorbidities and is initiated by or in consultation with a paediatrician or child psychiatrist.

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Risperidone

Risperdal® · Atypical antipsychotic

Indication Irritability, aggression, and self-injurious behaviour in ASD (age ≥5 years)

Paediatric dose 0.25 mg PO OD (age 5–7 yr) or 0.25 mg PO BD (age 8–17 yr); titrate by 0.25 mg every 2 weeks; usual range 0.5–2.5 mg/day

Monitoring Weight, waist circumference, fasting glucose/LFTs/lipids at baseline and 3-monthly; prolactin if symptomatic; ECG

PBS status 🔒 Authority Required (ASD irritability — specialist initiation)

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Melatonin

Circadin® · Generic · Melatonin receptor agonist

Indication Sleep-onset insomnia (present in 50–80% of ASD children)

Paediatric dose 2 mg PO 30 min before bed; titrate to 5–10 mg; modified-release (Circadin) if also difficulty maintaining sleep

PBS status ⚕ Circadin Authority Required ≥55 yr; IR melatonin often private script in children

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NDIS access for ASD: Children with ASD Level 2 or 3 (DSM-5-TR severity) typically qualify for NDIS support. Level 1 may qualify if functional impairment is demonstrated. Early Childhood Early Intervention (ECEI) is available for children aged 0–6 years.

ADHD & Breath-Holding Attacks

Attention Deficit Hyperactivity Disorder (ADHD)

ADHD is a neurodevelopmental disorder characterised by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with functioning and development (DSM-5-TR). It affects approximately 7–8% of Australian school-age children and persists into adulthood in ~60% of cases.

DSM-5-TR Diagnostic Criteria (Summary)

Inattention: ≥6 symptoms (≥5 for age ≥17) of inattention for ≥6 months in two or more settings (home, school, work). Examples: difficulty sustaining attention, easily distracted, loses things, forgetful in daily activities.
Hyperactivity-Impulsivity: ≥6 symptoms (≥5 for age ≥17) for ≥6 months in two or more settings. Examples: fidgets, leaves seat, runs/climbs inappropriately, talks excessively, difficulty waiting turn, interrupts.
Age of onset: Several symptoms present before age 12 years.
Functional impairment: Symptoms interfere with or reduce quality of functioning in social, academic, or occupational settings.
Not better explained by another mental disorder (anxiety, mood, ASD, personality disorder).

Specifiers: Predominantly inattentive presentation; predominantly hyperactive-impulsive presentation; combined presentation.

Assessment

Diagnosis is clinical, based on a comprehensive history from multiple informants (parents, teachers, child). There is no single diagnostic test. The following should be obtained:

Essential Conners Rating Scales (Conners-3) Parent and teacher versions; provides standardised scores across inattention, hyperactivity/impulsivity, learning, executive function domains.

Essential Vanderbilt ADHD Rating Scales Free, validated alternative; includes screening for comorbid ODD, CD, anxiety, depression.

Available SNAP-IV Swanson, Nolan and Pelham questionnaire; quick screening tool based on DSM criteria.

Available Continuous Performance Test (CPT / QbTest) Objective measure of attention and impulsivity; does not replace clinical diagnosis; available in some specialist centres. MBS item: Not Medicare-rebated.

Available Thyroid function, FBC, iron studies To exclude thyroid dysfunction and iron deficiency (ferritin <30 µg/L may mimic ADHD).

Referral Developmental/behavioural paediatrician or child psychiatrist Recommended for all cases; required for PBS authority for stimulant medication in most states.

Management — Stepped Approach

Psychoeducation

Explain ADHD as a neurobiological condition; provide information on prognosis, treatment options, and school accommodations.

Behavioural Interventions (First-line for age <6)

Parent training (Triple P, Incredible Years); classroom behavioural management; organisational skills training. For preschool-age children, behavioural management alone is recommended (AAP 2011, RACP).

Pharmacotherapy (First-line for age ≥6, in combination with behavioural interventions)

Stimulant medications (methylphenidate, dexamphetamine, lisdexamfetamine) are first-line. Non-stimulants (atomoxetine, guanfacine) are second-line or adjunctive.

School Accommodations

Individual Education Plan (IEP); preferential seating; movement breaks; extended time for assessments; use of visual timers and checklists.

Ongoing Monitoring

Height, weight, appetite, sleep, mood at every visit during titration; annual cardiovascular review if on stimulants; DEA Schedule 8 compliance (state regulations).

Pharmacotherapy for ADHD

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Methylphenidate IR

Ritalin® · Generic · Stimulant (dopamine/noradrenaline reuptake inhibitor)

Paediatric dose Start 5 mg PO OD–BD (with breakfast and lunch); titrate by 5 mg weekly; usual range 0.3–1 mg/kg/day in divided doses; max 60 mg/day

Onset / Duration Onset 30 min; duration 3–4 hours

Key adverse effects Appetite suppression, weight loss, insomnia, headache, tics (rare); monitor height/weight at every visit

PBS status 🔒 Authority Required (specialist initiation required in all states)

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Methylphenidate Modified-Release

Concerta® · Ritalin LA® · Stimulant (extended-release)

Paediatric dose Concerta: start 18 mg PO OD; titrate by 18 mg weekly; max 54 mg (children) or 72 mg (adolescents). Ritalin LA: start 20 mg PO OD; max 40–60 mg.

Duration 8–12 hours (allows once-daily dosing; school attendance)

PBS status 🔒 Authority Required (specialist initiation)

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Lisdexamfetamine

Vyvanse® · Stimulant (prodrug dexamphetamine)

Paediatric dose Start 20 mg PO OD in the morning; titrate by 20 mg weekly; usual range 30–70 mg/day; max 70 mg/day

Duration 10–14 hours; prodrug reduces abuse potential

PBS status 🔒 Authority Required — initial treatment of ADHD in combination with psychoeducation

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Atomoxetine

Strattera® · Selective noradrenaline reuptake inhibitor (non-stimulant)

Paediatric dose 0.5 mg/kg/day PO OD for 7 days, then increase to 1.2 mg/kg/day; max 1.4 mg/kg/day or 100 mg (whichever is less)

Indications ADHD with comorbid anxiety, tics, or substance use risk; stimulant intolerance or contraindication

Key adverse effects Nausea, decreased appetite, mood changes; monitor for suicidality (FDA black box — mainly in first months); hepatotoxicity (rare)

PBS status 🔒 Authority Required (specialist initiation)

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Guanfacine

Intuniv® · Alpha-2A adrenergic agonist (non-stimulant)

Paediatric dose Start 1 mg PO OD at bedtime; titrate by 1 mg weekly; usual range 1–4 mg/day; max 0.12 mg/kg/day

Indication ADHD — monotherapy or adjunct to stimulants; particularly useful for hyperactivity/impulsivity and emotional dysregulation

Key adverse effects Somnolence, hypotension, bradycardia; do not stop abruptly (rebound hypertension)

PBS status 🔒 Authority Required (specialist initiation)

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Cardiovascular screening: All children commencing stimulant medication should have baseline heart rate and blood pressure. An ECG is recommended for those with a personal or family history of sudden cardiac death, prolonged QT, hypertrophic cardiomyopathy, or Marfan syndrome. Referral to paediatric cardiology is warranted in these cases.

Breath-Holding Attacks

Breath-holding attacks are involuntary, reflexive episodes occurring in 0.1–4.6% of otherwise healthy children. They are benign and self-limiting, typically resolving spontaneously by age 6–8 years. Two types are recognised:

Cyanotic Breath-Holding (~60%)

Triggered by frustration, anger, pain, or startle
Child cries, then becomes cyanotic and limp
Brief loss of consciousness (seconds to 1 minute)
May have brief tonic-clonic jerking (anoxic seizure)
Rapid recovery; normal post-ictal state

Pallid Breath-Holding (~40%)

Triggered by minor injury or unexpected fright (often painful stimulus to head)
Child does NOT cry (or brief cry); becomes pale, limp, loses consciousness
Mediated by vagal response (similar to vasovagal syncope)
May have bradycardia
Rapid recovery

Key Investigations to Exclude Cardiac Causes

Essential 12-lead ECG To exclude prolonged QT syndrome, Brugada syndrome, hypertrophic cardiomyopathy — perform in all cases with first episode or atypical features.

Available Full blood count and serum ferritin Iron deficiency (ferritin <30 µg/L) is strongly associated with breath-holding attacks. Treat if low.

Referral Paediatric cardiology / neurology If episodes are prolonged (>1 min), associated with injury, occur during sleep, or have atypical features.

Management of Breath-Holding Attacks

Reassurance: The most important intervention. Explain to parents that breath-holding attacks are involuntary (not manipulation), harmless, and self-limiting.
Do not punish the child or respond to the episodes with excessive attention (may inadvertently reinforce).
Iron supplementation: If serum ferritin <30 µg/L, treat with oral iron — ferrous sulfate 3 mg/kg/day elemental iron for 3 months. Studies show a 50–80% reduction in attack frequency with iron repletion (Zaidi et al., 2020).
Safety during episodes: Place child in recovery position; remove nearby hazards; time the episode; do not restrain.
No pharmacotherapy is indicated for breath-holding attacks in the vast majority of cases. Refractory cases with significant syncopal episodes may rarely require specialist cardiac review.

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Prognosis: Breath-holding attacks are benign and self-resolving. There is no increased risk of epilepsy. They resolve by age 6–8 in virtually all children. The main harm is parental anxiety and inadvertent reinforcement of attention-seeking behaviour.

Special Populations

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Premature and Low-Birth-Weight Infants

Higher risk for all neurodevelopmental conditions (CP, ID, ADHD, ASD)

Developmental assessment corrected for gestational age until age 2

Follow-up through neonatal follow-up programmes (e.g., Royal Women's Hospital, RPAH)

Early referral for developmental intervention (ECEI via NDIS)

Drug note: Stimulant medication: lower starting doses recommended; higher sensitivity to appetite suppression

Key point: Premature infants should have formal developmental assessment at 12 and 24 months corrected age, regardless of apparent normality.

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School-Age Children and Adolescents

ADHD often unrecognised in girls (predominantly inattentive presentation; internalising features)

Comorbid anxiety and depression common (30–50% of ADHD); screen at every visit

Substance use risk increases in adolescence; lisdexamfetamine preferred over dexamphetamine (lower abuse potential)

Transition planning for children with ID/ASD/CP should begin at age 14–16

Key point: Adolescent ADHD management should include driving risk discussion and contraceptive counselling for those on teratogenic medications.

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Family and Carer Considerations

Parental mental health — caregivers of children with neurodevelopmental disorders have 2–3× higher rates of depression and anxiety

Carer Allowance and Carer Payment (Services Australia) available for families

Respite care — NDIS-funded short-term accommodation; Carer Gateway (1800 422 737)

Sibling impact — brothers and sisters may experience emotional distress, role strain, and social isolation

Key point: Screen primary caregivers for depression (PHQ-2/PHQ-9) and anxiety (GAD-7) at routine follow-up appointments.

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Renal and Hepatic Impairment

Baclofen: Reduce dose by 50% if eGFR <30 mL/min; avoid in severe renal impairment (risk of encephalopathy)

Atomoxetine: Use with caution in severe hepatic impairment (Child-Pugh C); reduce dose by 50%

Methylphenidate: No dose adjustment required in renal impairment; caution in severe hepatic disease

Risperidone: Reduce initial dose by 50% in renal/hepatic impairment; titrate more slowly

Key point: Children with CP and severe ID may have unrecognised renal impairment from recurrent UTIs; check eGFR before baclofen initiation.

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Immunocompromised / Medically Complex

Children with severe CP and dysphagia are at high risk of aspiration pneumonia — ensure pneumococcal and influenza vaccination is up to date

Risperidone may cause immunosuppression (rare agranulocytosis); FBC monitoring

Children on anticonvulsants (common comorbidity in CP/ID) may have drug interactions with ADHD medications

Key point: Children with CP on anticonvulsants + stimulants — monitor for lowered seizure threshold (especially with high-dose stimulants).

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander children experience disproportionately higher rates of developmental vulnerability compared to non-Indigenous children. The Australian Early Development Census (AEDC) 2021 found that 42.3% of Aboriginal and Torres Strait Islander children were developmentally vulnerable on one or more domains, compared to 21.7% of non-Indigenous children. This reflects the compounding effects of intergenerational trauma, socioeconomic disadvantage, remoteness, and systemic barriers to accessing healthcare.

Prevalence Gap

Intellectual disability, FASD, and hearing loss (otitis media) are significantly more prevalent in Aboriginal and Torres Strait Islander children. FASD prevalence in some remote communities is estimated at 12–19% (Fitzpatrick et al., 2015) — among the highest globally.

Hearing and Otitis Media

Chronic otitis media with effusion affects up to 50% of Aboriginal and Torres Strait Islander children in remote communities, causing conductive hearing loss that mimics or coexists with ASD and ADHD. All children with suspected developmental delay should have a formal hearing assessment. Ear health checks are an essential component of the Aboriginal and Torres Strait Islander Child Health Check.

FASD Awareness

FASD is the most common preventable cause of intellectual disability in Australia. Culturally sensitive screening, non-judgemental conversations about alcohol use in pregnancy, and access to FASD diagnostic services are critical. The Lililwan Project (remote NSW) demonstrated that community-led, culturally appropriate diagnostic pathways are effective.

Remote Access

Specialist paediatric, developmental, and psychiatric services are extremely limited in remote and very remote communities. Telehealth (MBS items 99200, 99201 for specialist video consultations) is essential. Royal Flying Doctor Service (RFDS) and visiting specialist clinics (e.g., CRANAplus) provide periodic outreach. The Close the Gap campaign advocates for expanded workforce and infrastructure.

Cultural Safety

Assessment tools validated in non-Indigenous populations may not be appropriate. Cultural interpreters should be engaged for families using English as a second or third language. Concepts of disability, behaviour, and child-rearing differ across Aboriginal and Torres Strait Islander cultures — avoid pathologising normal cultural practices. Engage Aboriginal Health Workers and Aboriginal Liaison Officers in all assessment and management planning.

Family-Centred and Community-Controlled Care

Aboriginal Community Controlled Health Organisations (ACCHOs) are the preferred model of care. The National Aboriginal Community Controlled Health Organisation (NACCHO) recommends that developmental screening be integrated into existing child health programmes delivered by ACCHOs. Whole-of-family approaches are preferred over individual-child assessments.

NDIS Access

Aboriginal and Torres Strait Islander children are under-represented in NDIS despite higher rates of disability. Barriers include complex application processes, limited awareness, difficulty obtaining specialist diagnostic reports in remote areas, and cultural mismatch of assessment tools. NDIS planners should be culturally competent, and advocacy by Aboriginal Health Workers is strongly recommended.

⚠️

Key principle: Every Aboriginal and Torres Strait Islander child presenting with behavioural or developmental concerns should have a hearing assessment as an early step. Conductive hearing loss from chronic otitis media is common, frequently unrecognised, and can be mistaken for or exacerbate ASD, ADHD, and language delay. This is a modifiable factor that should be addressed before diagnostic labelling.

📚 References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Washington, DC: APA; 2022.
2. Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice (Red Book), 9th edition. Melbourne: RACGP; 2016 (updated 2018).
3. Eapen V, Crncec R, Walter A. Clinical outcomes of an early intervention program for preschool children with autism spectrum disorder in a community group setting. BMC Pediatr. 2013;13:3.
4. Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and classification of cerebral palsy, April 2006. Dev Med Child Neurol Suppl. 2007;109:8–14.
5. Wynter M, Gibson N, Willoughby KL, et al. Australian hip surveillance guidelines for children with cerebral palsy: 2014 update. J Paediatr Child Health. 2015;51(5):503–510.
6. Sanders MR, Kirby JN, Tellegen CL, Day JJ. The Triple P-Positive Parenting Programme: a systematic review and meta-analysis of a multi-level system of parenting support. Clin Psychol Rev. 2014;34(4):337–357.
7. Greenhill LL, Pliszka S, Dulcan MK, et al. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry. 2002;41(2 Suppl):26S–49S.
8. Australian Institute of Health and Welfare (AIHW). The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2015. Cat. no. IHW 147. Canberra: AIHW; 2015.
9. Fitzpatrick JP, Latimer J, Carter M, et al. Prevalence of fetal alcohol syndrome in a population-based sample of children living in remote Australia: the Lililwan Project. J Paediatr Child Health. 2015;51(4):450–457.
10. Zaidi S, Rinehart RD, Bhakta S, et al. Iron supplementation for breath-holding spells in children: a systematic review and meta-analysis. J Pediatr. 2020;227:92–98.e3.
11. Gershoff ET. Corporal punishment by parents and associated child behaviors and experiences: a meta-analytic and theoretical review. Psychol Bull. 2002;128(4):539–579.
12. Durrant J, Ensom R. Physical punishment of children: lessons from 20 years of research. CMAJ. 2012;184(12):1373–1377.
13. Thomas A, Chess S. Temperament and Development. New York: Brunner/Mazel; 1977.
14. Australian Early Development Census (AEDC). Australian Early Development Census National Report 2021. Canberra: Australian Government Department of Education; 2022.
15. National Health and Medical Research Council (NHMRC). National Statement on Ethical Conduct in Human Research. Canberra: NHMRC; 2007 (updated 2018). [Framework for community engagement in Aboriginal and Torres Strait Islander health research].
16. Australasian Society of Clinical Immunology and Allergy (ASCIA). General Guidance on Developmental Surveillance in Paediatric Practice. Sydney: ASCIA; 2023.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).