Disruptive Behaviours

8/8/2019 Disruptive Behaviours

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DISRUPTIVE BEHAVIOURSDISRUPTIVE BEHAVIOURS

ININCHILDRENCHILDREN


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Autism SpectrumDisorders or Pervasive

Developmental Disorder


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Ty pes of PDD (ICD-10)

Childhood autismChildhood autismautistic ds, infantile autism, infantile psychoses, autistic ds, infantile autism, infantile psychoses, Kanner s syn d romeKanner s syn d rome

At y pical autismAt y pical autismRetts s y ndromeRetts s y ndromeChildhood disintegrative dsChildhood disintegrative ds

Overactive ds associated with MROveractive ds associated with MRAspergers s y ndromeAspergers s y ndromePDDPDD-- not otherwise specifiednot otherwise specified


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Diagnosis: 3 main areas of impairment inPDD or ASD

Delay and abnormal quality in:

reciprocal social interactionlanguage and communicationimaginative thinking - restricted,

repetitive activities and interests&

earl y onset : before age 3


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Social impairment

Qualitative impairment in reciprocal socialQualitative impairment in reciprocal socialrelationshipsrelationshipsnonnon- -verbal cues: poor e y e contact, facialverbal cues: poor e y e contact, facial

expressions, bod y postures, gesturesexpressions, bod y postures, gesturesfailure to develop peer relationshipfailure to develop peer relationshipfail to share enjo y ment or seek comfort whenfail to share enjo y ment or seek comfort whenhurt (lack of pointing, requesting)hurt (lack of pointing, requesting)difficulties with understanding social cuesdifficulties with understanding social cueslack of social empath y (difficult y tolack of social empath y (difficult y torecognise others emotions)recognise others emotions)


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L anguage & communication

Dela y in receptive and expressivelanguagestereot y ped or repetitive use of language

idios y ncratic use of wordsunable to initiate or sustain aconversation (those with speech)echolalia, pronoun reversal, invented

reduced gestures or poorl y co-ordinated(abnormal pointing)lack of social imitative or pretend pla y


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Repetitive stereot y ped activities andinterests

Rigid and inflexible thought processesresistance to change, insist on sameroutines, ritualistic behaviours(length y mealtime ritual)repetitive activities and interests(complex or simple)- hand flapping,twirling objects, fascinated withunusual parts of objects, samesegment TV show)persistent preoccupation with parts of objects


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Other features: not required fordiagnosis

Unusual responses to sensor y stimuli egcertain sounds, fascination b y certainvisual stimuli, dislike gentle touch, butenjo y s firm pressurepoor motor co-ordinationover or underactivit y

food fadserratic sleeping patternsabnormalities of mood- excitement/miser y


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Age of Onset

Dela y or abnormal functioning in atleast one area must be before age 3y ears


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PrevalenceChildhood autism:3-4 per 10,000 population20 per 10,000 (broader definition)

Asperger S y ndrome36 per 10,000

Male preponderance


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Differential d iagnoses of childhoo d autism

DeafnessDevelopmental language disorderMental retardation with autistic featuresMental retardation without autisticfeaturesIntense earl y deprivationPervasive developmental disorders:

Asperger S y ndrome, Retts s y ndrome,Degenerative disorder, at y pical

autism, PDD-not otherwise specified


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Treatment planTreatment plan

Establish goals for educationalEstablish goals for educationalpurposespurposes

Establish target symptoms forEstablish target symptoms forinterventioninterventionCoCo--morbid conditionsmorbid conditions

MonitoringMonitoringMultiple domains of functioningMultiple domains of functioningMedicationMedication


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The little RascalsThe little Rascals

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Attention Deficit Hyperactive Disor derAttention Deficit Hyperactive Disor der(ADHD)(ADHD)


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Hyperkinetic child ren


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Hyperactive parents

all manner of behaviours e.g. frequent night awakenings, talking lou d ly, naughtiness,

exu berance

depen ds on attitu des an d tolerance of parents MUST always pay attention to the stage of

develo pment when decid ing normality an d abnormality


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Hyperactive Children

Hyperactive

psychiatrists more restrictive definition

p restlessness

p inattentiveness

p impulsiveness


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Hyperactive Children

Overactive : increase in amount an d tem po of pur poseful activity increase in num ber of pur poseless minor movements

irrelevant to tasksT e.g. wriggle an d squirm in seat

fidget with objectsrestless

una b le to su pp ress activity when stillness is require dS e.g. in classroom or at meal ta b le


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Core sym p tomsCore sym p toms

HyperactivityHyperactivity More active than child ren their ageMore active than child ren their age

Inattentive Inattentive Short attention spanShort attention span

ImpulsiveImpulsive Poor impulse controlPoor impulse control

PervasivePervasive Sym p toms occur across all situationsSym p toms occur across all situations

Little Rascals Little Rascals


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Hyperactivity Hyperactivity

Fidgets with han ds or feetFidgets with han ds or feetSquirms in seatSquirms in seat

Runs about or clim bs excessivelyRuns about or clim bs excessivelyDifficulty p laying or engaging in leisure activities Difficulty p laying or engaging in leisure activities quietlyquietlyTalks excessivelyTalks excessivelyAlways on the goAlways on the goDescri bed as if driven by a motorDescri bed as if driven by a motor



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Inattentiveness Inattentiveness

Fails to give attention to detailsFails to give attention to detailsMakes careless mistakeMakes careless mistakeDo not follow through instructionsDo not follow through instructions

Fails to com p lete schoolwork, chores or dutiesFails to com p lete schoolwork, chores or dutiesReluctance to engage in tasks requiring sustain Reluctance to engage in tasks requiring sustain mental effortsmental effortsDifficulty organizing tasks & activitiesDifficulty organizing tasks & activities

Easily d istracte dEasily d istracte dOften forgetful for their ageOften forgetful for their age



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Impulsive Impulsive

Blurts out answers before question Blurts out answers before question com p lete dcom p lete d

Difficulty awaiting their turnDifficulty awaiting their turnInterru p ts or intru des on othersInterru p ts or intru des on othersMakes poor judgementMakes poor judgement

Accident p roneAccident p rone



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Do you fit these criteriaDo you fit these criteria



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Epidemiology Epidemiology

Prevalent in 1Prevalent in 1--3% of child ren3% of child renMale : Female Male : Female 3:13:1

Hyperactivity dates back to p reHyperactivity dates back to p re --school yearsschool yearsReferral delaye d until p rimary schoolReferral delaye d until p rimary school Present with inattentiveness, learning d ifficulties Present with inattentiveness, learning d ifficulties

& d isru p tiveness& d isru p tiveness



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Management Management

Requires a multiRequires a multi --d iscip linary app roachd iscip linary app roach

Pharmacological treatmentPharmacological treatment

Psychological interventionPsychological intervention

Educational su pp ortEducational su pp ort



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PrognosisPrognosis

Hyperactivity wanes in adolescenceHyperactivity wanes in adolescence30% have resi dual sym p toms in adulthoo d30% have resi dual sym p toms in adulthoo d Restless & inattentiveRestless & inattentive

30% have no sym p toms with goo d functioning30% have no sym p toms with goo d functioning Choose job which allow free dom of movementChoose job which allow free dom of movement

30% continuous d isp lay of sym p tom30% continuous d isp lay of sym p tom Develo p other psycho pathologiesDevelo p other psycho pathologies

E.g. su bstance abuse & antiE.g. su bstance abuse & anti --social personalitysocial personality



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CONDUCT DISORDERCONDUCT DISORDER


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Con duct Disor derCon duct Disor der

3 d omains :* d efiance of someone in authority

* aggressive when relating to others* antisocial behaviour

- violates other peo p le s rights ,

p ro perty or person


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None of these 3 is in itself - abnormal or pathological

Diso bed ience & d isru p tive behaviour- is part of normal behaviour- usually d iminish with maturity

Dx shoul d only be ma de when - behaviours are both extreme & p ersistent


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Epidemiology- evolves over time- often persistent- boys more than girls- 6% to 16% b oys- 2% to 9% girls- onset : b efore 10 y.o or during

adolescence


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Etiology

* no single factor* contri buting b iob io--p sychopsycho --socialsocial

factors


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Biological factorsBiological factors

- p ro pose d neurotransmitter imbalance- excessive testosterone- abnormal arousal with failure to calm

down after frustration


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Social factorsSocial factors- FamilyFamily

* chaotic home

* ver bal aggression * severe punishment* marital d iscor d* child abuse* p arental psycho pathology


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Social factorsSocial factors- CommunityCommunity

* economically dep rive d* high criminality* unsu pp ortive social network


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Psychological factorsPsychological factors- anger- frustration- hatre d- d issatisfaction


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Diagnostic Criteria ( DSM IV )

- d istur bance for 12 monthsinvolving at least 3 of the following

:


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Diagnostic Criteria

Often bullies , threatens or intimi datesOften starts fightsHas use d serious wea pons in fightsPhysically cruel to peo p lePhysically cruel to animalStealingHas force d someone into

sexual actsFire -setting to cause damage

Has destroye d other s p ropertyHas broken into a car or

houseCons othersOften out at night without permissionRan away from home overnight twiceOften truants , beginning un der

13 y.o


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Management

Prove d d ifficult to treatClinicians may feel overwhelme d

& ineffectiveMulti focus

- child focuse d

- family focuse d- community focuse d


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Factors p re d icting outcome

In the family- p oor outcome

* p arental psychiatric d /o* p arental criminality* high hostility* high d iscor d


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Opp ositional Defiant Disor derOpp ositional Defiant Disor der


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Characterise d b y an en during pattern Characterise d b y an en during pattern of behaviours :of behaviours :

negativistichostiledefiant

* in the absence of serious violation of - social norms or rights of others


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Caution :Caution :

Opp osing others is crucial to normal develo pment

Relates to esta b lishing- autonomy- forming identity

- setting inner stan dar ds & control


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Caution :Caution :

Child ren may have strong tem peramental p re d isposition

- strong will- strong p references- great assertiveness


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PathologyPathology

If power & control are issues for parentsOr if parents exercise authority for their own nee ds

- the ensuing struggle can set stage for develo pment of d /o


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PathologyPathology

What begins for a child as an effort to

esta b lish self -d etermination- is transforme d into a defense


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Diagnostic Criteria Diagnostic Criteria DSM IVDSM IV

Distur bance for 6 monthsInvolving at least 4 of the following sym p toms :


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Diagnostic Criteria Diagnostic Criteria DSM IVDSM IV

Often loses tem perOften argues withadultsOften defies adult requests & rules

Often deliberately annoys others

Often shifts b lame to others

Often touchy or easily annoye dOften angry & resentfulOften sp iteful or vind ictive


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Opp ositional Defiant Disor derEpidemiology

- p revalence in general population * about 1 .5 %

- male : female ratio* 2 : 1 to 3 : 1

- p eak age of onset* early childhoo d

- onset after age 10 years* unusual


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Opp ositional Defiant Disor der

Course* sym p toms persist to adulthoo d

- in up to 14 %* association with CD

- is strong

* 56 % shows imp rovement- with psychothera py


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M anagement

Ind ividual Psychothera py- to restore self -esteem

Behaviour mo d ification- reinforce & p raise app ro p riate behaviours

Counsel parentsParenting skillsSocial skills training- learn new strategies to develo p sense

of success in social situations


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Disruptive Behaviours

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