Behavioural Problems on the CCFP exam

Approach

• Look for medical, mental health and social causes before you explain the behaviour. In teens and young adults, keep psychosis on the list.
• A new slide after years of good marks points to something happening now. ADHD symptoms start before age 12, so new trouble at 15 does not fit.
• Use a standard tool where one exists (table below). A rating scale supports a diagnosis. It never makes one on its own.
• With consent, get the story from school, family or work. One informant is not enough.
• See the patient alone for part of the visit, and ask what they think is going on.
• Hearing or vision loss can look like poor attention. Ask about both, and test when the history or exam points there.
• Order blood tests, an EEG (brain wave test) or a brain scan only when the history or exam points there. A first psychosis with a normal neurological exam rarely needs a scan.

Approach

• See the teen alone for part of every visit, from about age 12. Explain the limits of privacy first.
• Ask permission before sensitive topics. Then ask open questions about how often and how much, not yes-or-no ones.
• Screen substance use with a teen tool such as the CRAFFT. Starting before 14, or using at least monthly, is tied to more harm.
• Ask about friends, breakups and bullying, online too.
• Ask about physical or sexual abuse, and fighting at home.
• Ask about mood and suicide in plain words: "Do you ever think about ending your life?"

Approach

• Ask what has changed at school or work, with friends and family, and in sleep.
• Ask how the patient feels about it. Look for fear, shame or low mood under the behaviour.
• Hopelessness raises suicide risk. Ask about it directly.
• Some youth use cannabis to cope with poor sleep or low mood. Ask what it does for them.
• Make it normal to talk about, without playing down the harms: "Many people your age have tried it." Then ask.
• Stay calm and neutral, whatever the answer.

Approach

• Plan several visits to finish an assessment. Many conditions look alike at first.
• Call it ADHD only when symptoms last over 6 months, show up in more than one setting and harm daily life.
• Ask the parents about their worries at every visit.
• Loss of skills at any age is a red flag. Act on it.
• Autism signs in a toddler: refer to early intervention now. Do not wait for the diagnosis.
• If concern remains but autism looks unlikely, refer for support and keep watching. Watch for autism signs through childhood.

Approach

• Ask first about thoughts of suicide or harming others, any plan, and access to means such as guns or pills.
• Refer a patient at high suicide risk for psychiatric assessment, through the emergency department if needed.
• ADHD care uses several parts: teach the family, train the parents, plan with the school, then add medicine where it helps.
• Under age 6, parent behaviour training comes first. Stimulants are not a first choice at that age.
• ADHD with defiance or aggression: start with behaviour treatment, then a stimulant. Try guanfacine, clonidine or atomoxetine before risperidone.
• Dementia with agitation: try non-drug steps first. Keep antipsychotics for severe distress or danger.
• Fit the plan to what your community offers: school supports, youth services, exercise programs.

Approach

• Name the goal you share: the teen doing well at school and at home.
• Acknowledge the parents' worries and needs out loud.
• Set limits calmly. Explain your reasons, not only the no.
• Use motivational interviewing: start with what the teen sees as important and one change they think they can make.
• Bring parents into the teen's plan only after you agree it with the teen.
• Book the next visit before they leave: within weeks, then regularly. In a teen at risk of suicide, no clear follow-up plan with support can be a reason for hospital care.