1. Behavioural problems in children. G Mustafa.

2. Case 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 out any organic cause for his symptoms – none found. You have done the physical examination and ruled 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 problem? Can u identify factors contributing to his behavioural problem? How would you go about managing this case?. How would you go about managing this case?.

3. Factors contributing to Richard’s behaviour. SEPERATION ANXIETY leading to school refusal. Anxiety disorder in mother Maternal over protection and over concern. Inadequate support to mother from his father. Over closeness and over dependence on mother Weak marital relationship of his parents.

4. 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 not all related to mental health issues. Children do not attend school for a variety of reasons not all related to mental health issues. Physical illness – commonest cause Physical illness – commonest cause Parental withholding Parental withholding Truanting – staying away from school without the school or parents know anything about it. Truanting – staying away from school without the school or parents know anything about it. School refusal - difficulty attending school due to emotional stress. School refusal - difficulty attending school due to 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.

5. 2 Big groups of non-attenders SCHOOL REFUSAL. Severe emotional,may include anxiety, somatic symptoms or temper tantrums. Severe emotional,may include anxiety, somatic symptoms or temper tantrums. Child remains symptoms free during weekends and holidays. Child remains symptoms free during weekends and holidays. Parents aware child’s absence Parents aware child’s absence No significant anti-social behaviour like fighting and offending No significant anti-social behaviour like fighting and offending Child feels safe at home and might be happy to do school work at home. Child feels safe at home and might be happy to do school work at home.TRUANCY Lack of anxiety or fear about attending school. Lack of anxiety or fear about attending school. Child conceals absence from school Child conceals absence from school Frequently shows disruptive problems such as stealing, fighting, lying) often in company of antisocial peers. Frequently shows disruptive problems such as stealing, fighting, lying) often in company of antisocial peers. Lacks interest in school work and doesn’t stay at home. Lacks interest in school work and doesn’t stay at home.

6. Interesting observations. Berg et al. (1993)– 80 children aged 13-15 who did not attend school for at least 40% of school term. Outcome: half the sample had no significant psychiatric problems, 1/3 rd had disruptive behaviour disorder, 1/5 th had severe anxiety or depressive disorder. Berg et al. (1993)– 80 children aged 13-15 who did not attend school for at least 40% of school term. Outcome: half the sample had no significant psychiatric problems, 1/3 rd had disruptive behaviour disorder, 1/5 th had severe anxiety or depressive disorder. Bools et al (1990)- 100 school refusal cases, = half met criteria for psychiatric problems Bools et al (1990)- 100 school refusal cases, = half met criteria for psychiatric problems boys = girls boys = girls Any age but peaks at school entry age then at transfer to secondary school and in adolescence. Any age but peaks at school entry age then at transfer to secondary school and in adolescence.

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

8. Causes for separation anxiety in school refusal 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)

9. Management of school refusal. CBT session for child and family, followed by gradual return to school CBT session for child and family, followed by gradual return to school Education and support treatment - parents Education 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 CBT 2- Individual interventions. i.e CBT 3- Family work to address specific family issues and assist family to cope with developmental challenges. 3- Family work to address specific family issues and assist family to cope with developmental challenges. Home tutoring as a last resort. Think about pupil referral units and ultimate re-integration into school. Home tutoring as a last resort. Think about pupil referral units and ultimate re-integration into school.

10. Management (cont.) Referral to paediatrician Referral to paediatrician Referral to CAMHS Referral to CAMHS Referral to EWO (Educational Welfare Officer, also called educational social worker) Referral to EWO (Educational Welfare Officer, also called 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.uk www.youngminds.org.uk www.schoolrefuser.org.uk Reference : WHO guide to mental and neurological health in primary care Case studies in child and adolescent mental health – MS Thambirajah Case studies in child and adolescent mental health – MS Thambirajah oxford specialist handbook – child and adolescent psychiatry. oxford specialist handbook – child and adolescent psychiatry.

11. CASE 2 Dylan, 8yr old, suspended from school for abusive and aggressive behaviour Dylan, 8yr old, suspended from school for abusive 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 behavioural problem? What risk factors can you identify for his behavioural problem? What advice and management can you think of? What advice and management can you think of?

12. CASE 2 cont. 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 home Inadequate supervision at home Exposure to media violence due to lack of supervision Exposure to media violence due to lack of supervision Lack of consistency in parenting styles due frequent changes in care givers – mum,dad, carers Lack of consistency in parenting styles due frequent changes in care givers – mum,dad, carers Family h/o of ASB and substance abuse. Family h/o of ASB and substance abuse.

13. CASE 2 (cont.) 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 aggressive behaviour across school and home. Consistent management of Dylan's violent and 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 development A formal cognitive assessment to identify gaps in development Parent management training and other psychological interventions. Parent management training and other psychological interventions.

14. Case 3 6 yr old boy with mum concerned about his behaviour since early childhood, now school has been complaining about his behaviour. 1- What's the diagnosis doctor! 2- Identify the risk factors? 3- How would you manage him ?

15. Oppositional Defiance Disorder (ODD) & Conduct Disorder ( CD) DSM IV ODD Markedly defiant and disobedient and provocative behaviour. Markedly defiant and disobedient and provocative behaviour. Active defiance of adult requests or rules. Active defiance of adult requests or rules. Deliberately annoying people. Deliberately annoying people. Angry, resentful and easily annoyed by other people Angry, resentful and easily annoyed by other people Blaming other people Blaming other people Loose temper readily. Loose temper readily. CONDUCT DISORDER Aggression to people – bullying threatening, intimidating, initiating physical fights Aggression to people – bullying threatening, intimidating, initiating physical fights Using weapons to cause damage, Using weapons to cause damage, Deceitfulness and theft Deceitfulness and theft Destruction of property, intentional fires. Destruction of property, intentional fires. Serious rule violations – staying out at night, running away from home, truancy. Serious rule violations – staying out at night, running away from home, truancy. Forcing others into sexual activity Forcing others into sexual activity

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

17. Characteristics of ODD Activity : Activity : – Child restless and difficult to settle since birth, - Feeding is usually a problem, - Lack of concentration or paying attention - Anxiety -Panic reaction when mum out of site. - Breath holding attacks –(18mnth – 4 yrs) hold breath at culmination of tantrum, response to frustration. In minority can result to LOC and brief convulsion  adds to parental anxiety

18. Aetiology and risk factors. Biological : - Familial clustering of ODD, CD, ADHD and substance use disorder. - Deficient nutrition and vitamins. - Abnormalities in prefrontal cortex. - Physical illness affecting CNS. - Adverse temperamental characters from birth. Psychological factors. - Deficient social learning and information processing. - Reading problems.

19. Aetiology and risk factors. Social factors - Low socioeconomic status - Peer relationship difficulties. - Parental mental health issues. - Parental drug abuse and criminality. - Parental disharmony, family dysfunction. - Erratic harsh discipline, rejection, low parental involvement in child’s activities. - Child maltreatment neglect and abuse.

20. Assessment. Clinical interview with parents: - Description of current problem - Developmental history of child - Medical history and physical examination - Parenting behaviour - Social history - Consider ethnic and cultural issues Interview with child or adolescent: - Child may not perceive their behaviour as a problem. Build a working relationship with the young person. - Observe child – parent relationship

21. Assessment. Collateral information: From teachers, others in regular contact with the young person, social worker, health visitor etc. Psychological and neuropsychological assessments Specific questionnaires and rating scales. - Child behavioural check list - Conner's parent and teacher rating scales. - Eyberg child behaviour inventory Differential diagnosis and presence of co-morbidities - ADHD - Mental retardation - PTSD, adjustment disorder, anxiety disorders - Depression, psychoses

22. Management Depends on severity and how disabling it is. Depends on severity and how disabling it is. Practical behavioural advice : change in parental behaviour – reward good behaviour, ignore or succeed in not giving attention to ‘bad’ behaviour Practical behavioural advice : change in parental behaviour – reward good behaviour, ignore or succeed in not giving attention to ‘bad’ behaviour - Negative reinforcement trap – parental command  child refuses to comply and protests  parent may give in or give up to stop child from protesting or complete task in a more timely manner  child learns loud protest and defiance are effective in overcoming undesirable parental directions. - Negative reinforcement trap – parental command  child refuses to comply and protests  parent may give in or give up to stop child from protesting or complete task in a more timely manner  child learns loud protest and defiance are effective in overcoming undesirable parental directions. - Positive reinforcement trap – child misbehaves  frequent, effective parental attention ( which otherwise would be considered as normal and good parenting )  a powerful reward to a difficult child. - Positive reinforcement trap – child misbehaves  frequent, effective parental attention ( which otherwise would be considered as normal and good parenting )  a powerful reward to a difficult child.

23. Management Parent management training : Parent management training : - Supported by substantial evidence. - NICE recommends group based parent training. - Focuses more on parents, addressing parental, family, community issues. - Daily behaviour charts and establishing points systems. - 40 – 50% parents drop out for a variety of reasons. - Also service is not widely available

24. Management Other psychological interventions : - Individual behavioural therapy, CBT. - school based interventions, family therapy. - No evidence to support effectiveness so far. Social measures – support with housing applications. Social measures – support with housing applications. Not much role for medication Not much role for medicationReference: Case studies and child and adolescent mental health, MS Thambirajah Oxford specialist handbook in child and adolescent psychiatry.

25. 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 consistent approach. Collaborate with regional CAMHS for a consistent approach. Monitor and support the family. Monitor and support the family. Ensure programmes are consistently conducted by carers. Ensure programmes are consistently conducted by carers. Assist with referral and coordination of other services needed. Assist with referral and coordination of other services needed.