Arifah Nur Istiqomah Departemen/SMF Ilmu Kedokteran Jiwa FK Unpad/RSHS

Normal behaviour Behavioural symptoms Behavioural disorder

Emile Durkham (Rules of Sociological Method )  Child and adolescent behaviour considered as normal as far as behavior does not lead to unrest in society, occurs within certain limits and unintentional

 Behavioural symptoms of varying levels of severity are very common in the population.  Only children and adolescents with a moderate to severe degree of psychological, social, educational or occupational impairment in multiple settings should be diagnosed as having behavioural disorders WHO Mgap, 2010

Behavioural disorders is an umbrella term that includes more specific disorders:  Attention deficit hyperactivity disorder*  Disruptive behavioral disorder:  Conduct Disorder  Oppositional Behavioral Problems WHO Mgap, 2010

Impaired attention  Breaking off from tasks and leaving activities unfinished; shifts frequently from one activity to another  Diagnosed as a disorder only if they are excessive for the child or adolescent’s age and intelligence, and affect their normal functioning and learning WHO mhGAP, 2010

Overactivity  Excessive restlessness, especially in situations requiring relative calm  Running, jumping around  Getting up from a seat when he or she was supposed to remain seated  Excessive talkativeness and noisiness  Fidgeting and wriggling WHO mhGAP, 2010

These disorders are compelling to understand and treat because:  Common in community  High rates of morbidity  High rates of associated psychiatric illness and psychopathology  Very costly for society Connor MD, 2009

 A recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures  Clearly more frequent, more intense, and more persistent across the child's development than is typically observed in individuals of similar age and developmental level.  The symptoms cause impairment in the child's social, academic, or occupational functioning Connor MD, 2009

 Repetitive and persistent pattern of dissocial, aggressive or defiant conduct  Such behaviour, when at its most extreme for the individual, should be much more severe than ordinary childish mischief or adolescent rebelliousness Connor MD, 2009

Corwin M, 2005

 Symptoms of ADHD persist into adolescence or adult life in approximately 50% of cases.  In the remaining 50 %, they may remit at puberty, or in early adulthood.  In some cases, the hyperactivity may disappear, but the decreased attention span and impulse-control problems persist Connor MD, 2009

 Many youth who exhibit negativistic or oppositional behaviors will find other forms of expression as they mature and will no longer demonstrate these behaviors in adulthood Connor MD, 2009

 Children who develop enduring patterns of aggressive behaviors that begin in early childhood and violate the basic rights of peers and family members, may be destined to an entrenched pattern of conduct disordered behaviors over time Sadock & Sadock, 2007

 Biological intervention: psychopharmacology  Psychosocial intervention

Do not use medication in primary care for behavioral problems without consulting a specialist WHO mhGAP, 2010

ADHD  Stimulant medication Methylphenidate  Non stimulant medication Atomoxetine HCL, venlavaxine, clonidine Sadock & Sadock, 2007

Disruptive Behavioral Problems:  Focus on impulsivity, affective lability, negative emotions (fear,irritability), explosive aggression  Psychopharmacological interventions are generally palliative and not curative: typical and atypical antipsychotics, mood stabilizers for explosive agression Connor MD, 2009

 Consistent about what the child is allowed and not allowed to do  Praise or reward the child after observe good behaviour and respond only to most important problem behaviours;  Avoid severe confrontations or foreseeable difficult situations.  Give clear, simple and short commands that Emphasize what the child should do rather than not do. WHO mhGAP, 2010

 Never physically or emotionally abuse the child. Make punishment mild and infrequent compared to praise.  As a replacement for punishment, use short and clear-cut “time out” after the child shows problem behaviour. (temporary separation from a rewarding environment, as part of a planned and recorded programme to modify behaviour).  Put off discussions with the child until parent become calm. WHO mhGAP, 2010

 Make a plan on how to address the child’s special educational needs WHO mhGAP, 2010

 Identify psychosocial impact on carers.  Assess the carer’s needs and promote necessary support and resources for their family life, employment, social activities and health  arrange for respite care, which means a break now and then when other trustable caregivers take over temporarily. WHO mhGAP, 2010