Intended for healthcare professionals

Practice Practice Pointer

Managing challenging behaviour in children with possible learning disability

BMJ 2019; 365 doi: (Published 02 May 2019) Cite this as: BMJ 2019;365:l1663
  1. Michael Absoud, consultant in paediatric neurodisability and senior clinical lecturer1,
  2. Holly Wake, research assistant2,
  3. Miriam Ziriat, research assistant2,
  4. Angela Hassiotis, professor of psychiatry of intellectual disability2
  1. 1Newcomen Centre at St Thomas’, St Thomas’ Hospital, London, UK
  2. 2Division of Psychiatry, University College London, London, UK
  1. Correspondence to: A Hassiotis a.hassiotis{at}

What you need to know

  • Challenging behaviour may be a manifestation of physical ill health in children and young people with a learning disability

  • Communication difficulties or autism spectrum disorder may exacerbate challenging behaviour in a child or young person with learning disability

  • Provide parents and family with appropriate strategies and prompt support to ensure effective management of challenging behaviour

A mother visits her general practitioner with her 3 year old daughter. She is concerned that the child is having regular “melt downs” and has become defiant when, for example, getting dressed or putting on her shoes. Her daughter is physically aggressive towards her and other family members. This happens often and sometimes lasts for up to an hour. The family has tried reward charts, time outs, and positive reinforcement.

Challenging behaviour is commonly defined as behaviour that is of an intensity, frequency, or duration that threatens the physical safety of the person or others or restricts access to community facilities.12 Challenging behaviour can first occur in childhood and can be difficult for parents, carers, and family members to understand and manage. Parents and carers may present to healthcare services, including their GP, with concerns about their children’s behaviour.

In some cases, challenging behaviour may be a sign of a known or an undiagnosed learning disability. This article gives particular advice about how to identify and manage children where a learning disability might be a contributing factor.

What you should cover

Often, behaviours perceived as challenging serve a purpose for the child or young person, such as producing sensory stimulation, attracting attention, and avoiding demands.3 Some behaviours may be a form of communication which needs to be understood.

Examples of challenging behaviours, sometimes reported by parents as “melt downs” or “defiance,” are

• Physical aggression (biting, scratching, hitting)

• Self injury (head banging, biting hands)

• …

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