Behavioural problems in children.

G Mustafa.

Case 1Case 1

Richard 12 yr old boy found to be missing school Richard 12 yr old boy found to be missing school

You have done the physical examination and ruled You have done the physical examination and ruled out any organic cause for his symptoms – none found.out any organic cause for his symptoms – none found.

It this a case of school refusal or truancy?It this a case of school refusal or truancy? Can u identify factors contributing to his behavioural Can u identify factors contributing to his behavioural

problem?problem? How would you go about managing this case?. How would you go about managing this case?.

Factors contributing to Richard’s Factors contributing to Richard’s behaviour. behaviour.

Weak marital relationship

of his parents.

Over closeness and

over dependence on mother

Inadequate support to mother

from his father.

Maternal over protection

and over concern.

Anxiety disorder in mother

SEPERATION ANXIETY leading to school refusal.

School Non-attendance. School Non-attendance. 10% absent from school at any one time. 10% absent from school at any one time. Children do not attend school for a variety of reasons Children do not attend school for a variety of reasons

not all related to mental health issues. not all related to mental health issues. Physical illness – commonest causePhysical illness – commonest cause Parental withholdingParental withholding Truanting – staying away from school without the Truanting – staying away from school without the

school or parents know anything about it. school or parents know anything about it. School refusal - difficulty attending school due to School refusal - difficulty attending school due to

emotional stress. emotional stress. Wilful or deliberate non-attendance Wilful or deliberate non-attendance Children can be off because of a variety of above. Children can be off because of a variety of above.

2 Big groups of non-attenders2 Big groups of non-attenders

SCHOOL REFUSAL. SCHOOL REFUSAL. Severe emotional ,may include Severe emotional ,may include

anxiety , somatic symptoms or anxiety , somatic symptoms or temper tantrums. temper tantrums.

Child remains symptoms free Child remains symptoms free during weekends and holidays. during weekends and holidays.

Parents aware child’s absenceParents aware child’s absence No significant anti-social No significant anti-social

behaviour like fighting and behaviour like fighting and offendingoffending

Child feels safe at home and Child feels safe at home and might be happy to do school work might be happy to do school work at home. at home.

TRUANCY TRUANCY Lack of anxiety or fear Lack of anxiety or fear

about attending school. about attending school. Child conceals absence Child conceals absence

from schoolfrom school Frequently shows disruptive Frequently shows disruptive

problems such as stealing, problems such as stealing, fighting, lying) often in fighting, lying) often in company of antisocial peers. company of antisocial peers.

Lacks interest in school Lacks interest in school work and doesn’t stay at work and doesn’t stay at home. home.

Interesting observations.Interesting observations. Berg et al. (1993)– 80 children aged 13-15 who did Berg et al. (1993)– 80 children aged 13-15 who did

not attend school for at least 40% of school term. not attend school for at least 40% of school term. Outcome: half the sample had no significant Outcome: half the sample had no significant psychiatric problems, 1/3psychiatric problems, 1/3rdrd had disruptive behaviour had disruptive behaviour disorder, 1/5disorder, 1/5thth had severe anxiety or depressive had severe anxiety or depressive disorder. disorder.

Bools et al (1990)- 100 school refusal cases, = half Bools et al (1990)- 100 school refusal cases, = half met criteria for psychiatric problemsmet criteria for psychiatric problems

boys = girlsboys = girls Any age but peaks at school entry age then at transfer Any age but peaks at school entry age then at transfer

to secondary school and in adolescence . to secondary school and in adolescence .

Causes of school refusal. Causes of school refusal.

Separation anxietySeparation anxiety : : - Most common cause- Most common cause- Common in younger ageCommon in younger age- Can have somatic symptomsCan have somatic symptomsSocial phobia:Social phobia: – – Common in older childrenCommon in older children - Have more severe school refusal. - Have more severe school refusal. Other disorders:Other disorders: - GAD or depression – seen mostly in adolescentsGAD or depression – seen mostly in adolescents- Specific phobias e.g.. Public transport. Specific phobias e.g.. Public transport. - Oppositional defiant behaviour. (ODD)Oppositional defiant behaviour. (ODD)

Causes for separation anxiety in school Causes for separation anxiety in school refusal casesrefusal cases. .

Negative re-enforcement

Avoidance of negative emotions.

( stress, anxiety, depression)

Escape from evasive social situations

( bullying) or evaluative situations

( interaction with others / teachers)

Positive re-enforcement

Obtaining attention from significant others

(parents)

Seeking tangible re-enforcement

or rewards (watching TV, sleeping)

Management of school refusal.Management of school refusal. CBT session for child and family, followed by gradual return CBT session for child and family, followed by gradual return

to schoolto school Education and support treatment - parentsEducation and support treatment - parents Three pronged approach in most cases :Three pronged approach in most cases : 1- Liaison with school to implement gradual re introduction. 1- Liaison with school to implement gradual re introduction. 2- Individual interventions. i.e CBT2- Individual interventions. i.e CBT 3- Family work to address specific family issues and assist 3- Family work to address specific family issues and assist

family to cope with developmental challenges.family to cope with developmental challenges. Home tutoring as a last resort . Think about pupil referral units Home tutoring as a last resort . Think about pupil referral units

and ultimate re-integration into school. and ultimate re-integration into school.

Management (cont.)Management (cont.) Referral to paediatrician Referral to paediatrician Referral to CAMHS Referral to CAMHS Referral to EWO (Educational Welfare Officer, also called Referral to EWO (Educational Welfare Officer, also called

educational social worker) educational social worker) Some areas have local tutorial units ( pupil referral units)Some areas have local tutorial units ( pupil referral units) Usefull sites for parents / carers : Usefull sites for parents / carers : www.ace-ed.org.ukwww.ace-ed.org.ukwww.youngminds.org.ukwww.youngminds.org.ukwww.schoolrefuser.org.ukwww.schoolrefuser.org.uk

Reference : WHO guide to mental and neurological health in primary careReference : WHO guide to mental and neurological health in primary care Case studies in child and adolescent mental health – MS ThambirajahCase studies in child and adolescent mental health – MS Thambirajah oxford specialist handbook – child and adolescent psychiatry.oxford specialist handbook – child and adolescent psychiatry.

CASE 2CASE 2

Dylan, 8yr old, suspended from school for Dylan, 8yr old, suspended from school for abusive and aggressive behaviourabusive and aggressive behaviour

What condition would his behaviour fit into?What condition would his behaviour fit into? What risk factors can you identify for his What risk factors can you identify for his

behavioural problem?behavioural problem? What advice and management can you think What advice and management can you think

of?of?

CASE 2 cont.CASE 2 cont.

Risk factors for Dylan's behaviour: Risk factors for Dylan's behaviour: Poor or non existent family network or support. Poor or non existent family network or support. Inadequate supervision at homeInadequate supervision at home Exposure to media violence due to lack of Exposure to media violence due to lack of

supervisionsupervision Lack of consistency in parenting styles due frequent Lack of consistency in parenting styles due frequent

changes in care givers – mum ,dad, carers changes in care givers – mum ,dad, carers Family h/o of ASB and substance abuse. Family h/o of ASB and substance abuse.

CASE 2 (cont.)CASE 2 (cont.)

Management plan :Management plan : Parental Education – very important. Parental Education – very important. Reduction of risk factors which have been identified. Reduction of risk factors which have been identified. Consistent management of Dylan's violent and Consistent management of Dylan's violent and

aggressive behaviour across school and home. aggressive behaviour across school and home. Regular meetings with mother and his school. Regular meetings with mother and his school. A formal cognitive assessment to identify gaps in A formal cognitive assessment to identify gaps in

developmentdevelopment Parent management training and other psychological Parent management training and other psychological

interventions. interventions.

Case 3Case 3

6 yr old boy with mum concerned about his 6 yr old boy with mum concerned about his behaviour since early childhood, now school behaviour since early childhood, now school has been complaining about his behaviour.has been complaining about his behaviour.

1- What's the diagnosis doctor! 1- What's the diagnosis doctor!

2- Identify the risk factors? 2- Identify the risk factors?

3- How would you manage him ?3- How would you manage him ?

Oppositional Defiance Disorder Oppositional Defiance Disorder (ODD) & Conduct Disorder ( CD) (ODD) & Conduct Disorder ( CD)

DSM IVDSM IV

ODD ODD Markedly defiant and Markedly defiant and

disobedient and provocative disobedient and provocative behaviour. behaviour.

Active defiance of adult Active defiance of adult requests or rules. requests or rules.

Deliberately annoying Deliberately annoying people. people.

Angry, resentful and easily Angry, resentful and easily annoyed by other peopleannoyed by other people

Blaming other peopleBlaming other people Loose temper readily. Loose temper readily.

CONDUCT DISORDERCONDUCT DISORDER Aggression to people – bullying Aggression to people – bullying

threatening, intimidating, threatening, intimidating, initiating physical fights initiating physical fights

Using weapons to cause damage, Using weapons to cause damage, Deceitfulness and theft Deceitfulness and theft Destruction of property, Destruction of property,

intentional fires. intentional fires. Serious rule violations – staying Serious rule violations – staying

out at night, running away from out at night, running away from home, truancy.home, truancy.

Forcing others into sexual Forcing others into sexual activityactivity

Characteristics of ODD.Characteristics of ODD. Control :Control : - Intractable and difficult to control Intractable and difficult to control - Conflicts at bedtime and meal times. Conflicts at bedtime and meal times. - Food refused and thrown around the room. Food refused and thrown around the room. - Prolong tantrums several times / day. Prolong tantrums several times / day. - Conflicts around getting ready for school. Conflicts around getting ready for school. AggressionAggression : : - Verbal if they can talk,Verbal if they can talk,- Physical mainly aimed at parents, rarely others, Physical mainly aimed at parents, rarely others, - Frustration results in immediate attack. This may Frustration results in immediate attack. This may

result in the child being isolated and found result in the child being isolated and found unacceptable. unacceptable.

Characteristics of ODDCharacteristics of ODD

ActivityActivity::

– – Child restless and difficult to settle since birth,Child restless and difficult to settle since birth,- Feeding is usually a problem, Feeding is usually a problem, - Lack of concentration or paying attentionLack of concentration or paying attention- Anxiety -Panic reaction when mum out of site. Anxiety -Panic reaction when mum out of site. - Breath holding attacksBreath holding attacks –( –(18mnth – 4 yrs) hold 18mnth – 4 yrs) hold

breath at culmination of tantrum, response to breath at culmination of tantrum, response to frustration. In minority can result to LOC and brief frustration. In minority can result to LOC and brief convulsionconvulsion adds to parental anxiety adds to parental anxiety

Aetiology and risk factors. Aetiology and risk factors.

Biological :Biological : - Familial clustering of ODD, CD, ADHD and Familial clustering of ODD, CD, ADHD and

substance use disorder.substance use disorder.- Deficient nutrition and vitamins. Deficient nutrition and vitamins. - Abnormalities in prefrontal cortex. Abnormalities in prefrontal cortex. - Physical illness affecting CNS. Physical illness affecting CNS. - Adverse temperamental characters from birth.Adverse temperamental characters from birth.Psychological factors.Psychological factors. - Deficient social learning and information processing. Deficient social learning and information processing. - Reading problems. Reading problems.

Aetiology and risk factors.Aetiology and risk factors.

Social factorsSocial factors - Low socioeconomic statusLow socioeconomic status- Peer relationship difficulties. Peer relationship difficulties. - Parental mental health issues. Parental mental health issues. - Parental drug abuse and criminality.Parental drug abuse and criminality.- Parental disharmony, family dysfunction.Parental disharmony, family dysfunction.- Erratic harsh discipline, rejection, low parental Erratic harsh discipline, rejection, low parental

involvement in child’s activities. involvement in child’s activities. - Child maltreatment neglect and abuse. Child maltreatment neglect and abuse.

Assessment. Assessment.

Clinical interview with parents:Clinical interview with parents:- Description of current problem Description of current problem - Developmental history of childDevelopmental history of child- Medical history and physical examinationMedical history and physical examination- Parenting behaviourParenting behaviour- Social history Social history - Consider ethnic and cultural issuesConsider ethnic and cultural issuesInterview with child or adolescent:Interview with child or adolescent:- Child may not perceive their behaviour as a problem . Build a Child may not perceive their behaviour as a problem . Build a

working relationship with the young person.working relationship with the young person.- Observe child – parent relationshipObserve child – parent relationship

Assessment.Assessment.Collateral information:Collateral information: From teachers, others in regular contact with the young person, From teachers, others in regular contact with the young person,

social worker, health visitor etc. social worker, health visitor etc.

Psychological and neuropsychological assessmentsPsychological and neuropsychological assessmentsSpecific questionnaires and rating scales. Specific questionnaires and rating scales. - Child behavioural check list- Child behavioural check list- Conner's parent and teacher rating scales. - Conner's parent and teacher rating scales. - Eyberg child behaviour inventory- Eyberg child behaviour inventory

Differential diagnosis and presence of co-morbiditiesDifferential diagnosis and presence of co-morbidities- - ADHDADHD- Mental retardationMental retardation- PTSD, adjustment disorder, anxiety disordersPTSD, adjustment disorder, anxiety disorders- Depression, psychosesDepression, psychoses

ManagementManagement Depends on severity and how disabling it is. Depends on severity and how disabling it is. Practical behavioural advicePractical behavioural advice : change in parental behaviour : change in parental behaviour

– reward good behaviour, ignore or succeed in not giving – reward good behaviour, ignore or succeed in not giving attention to ‘bad’ behaviourattention to ‘bad’ behaviour

- - Negative reinforcement trapNegative reinforcement trap – parental command – parental command child child refuses to comply and protestsrefuses to comply and protests parent may give in or give up parent may give in or give up to stop child from protesting or complete task in a more timely to stop child from protesting or complete task in a more timely manner manner child learns loud protest and defiance are effective child learns loud protest and defiance are effective in overcoming undesirable parental directions. in overcoming undesirable parental directions.

- - Positive reinforcement trapPositive reinforcement trap – child misbehaves – child misbehaves frequent , frequent , effective parental attention ( which otherwise would be effective parental attention ( which otherwise would be considered as normal and good parenting )considered as normal and good parenting ) a powerful a powerful reward to a difficult child. reward to a difficult child.

ManagementManagement Parent management trainingParent management training : : - Supported by substantial evidence. Supported by substantial evidence. - NICE recommends group based parent training. NICE recommends group based parent training. - Focuses more on parents, addressing parental , Focuses more on parents, addressing parental ,

family, community issues.family, community issues.- Daily behaviour charts and establishing points Daily behaviour charts and establishing points

systems.systems.- 40 – 50% parents drop out for a variety of reasons. 40 – 50% parents drop out for a variety of reasons. - Also service is not widely availableAlso service is not widely available

ManagementManagement

Other psychological interventionsOther psychological interventions : : - Individual behavioural therapy, CBT.Individual behavioural therapy, CBT.- school based interventions, family therapy. school based interventions, family therapy. - No evidence to support effectiveness so far. No evidence to support effectiveness so far. Social measuresSocial measures – support with housing – support with housing

applications. applications. Not much role for medicationNot much role for medication

Reference: Reference: Case studies and child and adolescent mental health, MS Thambirajah Case studies and child and adolescent mental health, MS Thambirajah Oxford specialist handbook in child and adolescent psychiatry. Oxford specialist handbook in child and adolescent psychiatry.

Where do we fit in?Where do we fit in?

Validate parents concern. Validate parents concern. Assess and refer for diagnosis and treatment. Assess and refer for diagnosis and treatment. Collaborate with regional CAMHS for a Collaborate with regional CAMHS for a

consistent approach. consistent approach. Monitor and support the family. Monitor and support the family. Ensure programmes are consistently conducted Ensure programmes are consistently conducted

by carers. by carers. Assist with referral and coordination of other Assist with referral and coordination of other

services needed. services needed.