Dr Merryn Young

Division of Child and Adolescent Psychiatry

Red Cross War Memorial Children’s Hospital

Overview What we mean by behaviour problems?

Examples

What does the behaviour mean?

Approach to causes

Disruptive behaviour disorders

Principles of management

Non-pharmacological

Pharmacological

What are Behaviour Problems? Infants Toddlers

Caleb 3/12: “colicky”, difficult to soothe, excessive crying, irregular sleep patterns, fussy eater.

James 2 ½: tantrums, power struggles, oppositionality, separation issues.

What are Behaviour Problems? Prepubertal Adolescence

Josh 9: disobedient, unpopular, in conflict, “cheeky”, dishonest, aggressive outbursts

Abigail 16: rebellious, moody, aggressive, risk-taking behavior (sex, drugs)

Causes

• Psychiatric disorder in the child

• GMC

• External stressors

• Parenting issues

• Inappropriate parenting

• Parental psychopathology

• Temperament

• Developmental Stage

• Sibling rivalry

Normal External

Psycho-pathology

Internal

Causes

• Psychiatric disorder in the child

• GMC

• External stressors

• Parenting issues

• Inappropriate parenting

• Parental psychopathology

• Temperament

• Developmental Stage

• Sibling rivalry

Normal External

Psycho-pathology

Internal

Temperament Thomas and Chess Activity level Rhythmicity (regularity) – sleeping/eating/etc. Approach/withdrawal Adaptability Threshold of responsiveness Intensity of reaction Quality of mood Distractibility Attention span and persistence

Easy temperament Difficult temperament Slow-to-warm-up temperament

Goodness of fit

Developmental Stages Erikson Age Psycho-social

crisis Existential crisis Examples

0-2 years Basic trust vs. mistrust

Can I trust the world? Parent adapts to child’s routine

2-4 years Autonomy vs. shame and doubt

Is it OK to be me? “No!” Basic job description

4-5 years Initiative vs. guilt

Is it OK for me to do, move and act?

Separation issues, sibling rivalry

5-12 years Identity vs. role confusion

Can I make it in the world of people and things?

Negotiating success/failure/status

13-19 years Intimacy vs. isolation

Who am I? What can I be?

Peer group, separation from parents, individuality, romance, future plans

Sibling Rivalry Aggression towards sibling(s)

Feelings of displacement

Perceptions of favouritism

Need of any child to feel “special” & “best-beloved”

Formulation and acceptance of underlying feelings, reassurance, establishment of “fair” rules, alternative methods of communication

Causes

• Psychiatric disorder in the child

• GMC

• External stressors

• Parenting issues

• Inappropriate parenting

• Parental psychopathology

• Temperament

• Developmental Stage

• Sibling rivalry

Normal External

Psycho-pathology

Internal

External Stressors Unmet basic needs? Food, shelter, contact

Community instability/violence

Abuse (physical, sexual or emotional)

Inappropriate/inadequate educational system

Loss of attachment figures/parental conflict

Chaotic household/inconsistent discipline

Under-/over-stimulated/uncontained

Parental Pathology Inappropriate expectations: ignorance/cognitive

impairment

Personality pathology: especially cluster B

Substance abuse

Mood disorders

Anxiety disorders

Psychosis

Some Parents Need More Help

Causes

• Psychiatric disorder in the child

• GMC

• External stressors

• Parenting issues

• Inappropriate parenting

• Parental psychopathology

• Temperament

• Developmental Stage

• Sibling rivalry

Normal External

Psycho-pathology

Internal

General Medical Conditions

Chronic hunger/illness with fatigue & irritability

Sensory disorders – hearing, vision

Anxiety-provoking illnesses: cardiac, respiratory

“Disfiguring” conditions: fear & anger

Endocrine disorders

CNS disorders: e.g., delirium, seizure disorders

Substance/medication-induced

Causes

• Psychiatric disorder in the child

• GMC

• External stressors

• Parenting issues

• Inappropriate parenting

• Parental psychopathology

• Temperament

• Developmental Stage

• Sibling rivalry

Normal External

Psycho-pathology

Internal

Psychiatric Disorders in the Child Disruptive behavioural disorders

ADHD, ODD, CD

Reactive attachment disorder

Developmental disorders: global, specific and pervasive

Anxiety disorders, especially PTSD

Mood disorders

Eating disorders

Psychotic disorders

Disruptive Behaviour Disorders

Attention Deficit / Hyperactivity Disorder

Impaired attention and concentration

Excessive motor activity level

Impulsivity

Difficulties at home and school

Disciplinary conflicts

Negative spiral

Self esteem damage in child and parents

Oppositional Defiant Disorder

Family approach

usually helpful; may need individual

treatment for comorbid disorders

Resentful and

unhappy

Disobedient “on

principle”

Frequently dysthymic/depressed

Often provoke conflict

Unpopular and feel unloved

Conduct Disorder

Violation of major

societal norms

Vulnerable to depressive

disorders and

substance abuse

Often comorbid learning disorders

Usually severe family

pathology present

Early psychosocial intervention

is crucial

Isolated Antisocial Symptoms

Stealing: “comfort” stealing, “buying” friends,

feelings of deprivation

Arson: curiosity, mental

retardation, conduct disorder

Vandalism: peer group pressure,

anger, envy

Truanting: learning

disorders, anxiety

disorders, school-related stressors, etc.

“Paediatric Bipolar Disorder”

Very difficult diagnosis to make

in prepubertal children

Danger of overlooking other

pathology or family issues

Bipolar disorder does occur in a

small number of children and a

larger number of adolescents, and

requires psychiatric assessment and

management

General Principles

Thorough medical and

developmental history

Ascertain onset, extent and course of symptoms

• Is it normal or not?

Identify family/societal problems and

refer appropriately

Identify medical and/or

psychiatric conditions and manage/refer appropriately

The Hazards of a Non-holistic Approach

First-line Treatment

First line of treatment is

referral to good parenting skills resource unless medication is

strongly indicated

Psycho-education, Cognitive,

Behavioural

Medication in Behavioural Disorders

Not as first line treatment except

for Methylphenidate in children with

clear AD/HD

Prescription of an antipsychotic

medication as a first line treatment

for a disruptive child is not good

practice

Significant adverse effects require strong clinical

grounds for use, an acceptable

evidence base in that specific

disorder in that specific age group, and a favourable risk:benefit ratio

Specialists may use antipsychotic

medications and/or mood

stabilisers as a last resort in

behavioural disorders

Use of Antipsychotic Medications

Not first line treatment in any accepted

protocol

Most evidence is in

developmental disorders

Some evidence for reduction of

impulsive aggression, not premeditated

Serious concerns around rapid-

onset metabolic side effects, hyper-

prolactinaemia, neuroleptic malignant syndrome

Mood Stabilisers in Behavioural Disorders

Only with adequate evidence of a mood

disorder (bipolar disorder, severe depression) or

impulsive aggression

associated with PTSD

Side effect profiles cause for concern:

• Valproate – hepatic dysfunction, poly-cystic ovarian syndrome (?)

• Lamotrigine – dermatological

• Lithium – renal and thyroid

FDA Approved Medications

Aripiprazole, Olanzapine, Quetiapine, Risperidone:

Schizophrenia: (13-17)

Aripiprazole, Quetiapine, Risperidone:

BMD I mania/mixed:

(10-17)

Risperidone

(5-17),

Aripiprazole

(6-17):

Irritability, aggression in

Autism

Ziprasidone:

BMD I mania:

(10-17)

Recent Controversies TIME magazine By MAIA SZALAVITZ| August 9, 2012 |

Antipsychotic Prescriptions in Children Have Skyrocketed: Study “The dramatic rise of antipsychotic prescribing in youth occurred in

conjunction with the illegal marketing of the drugs by their makers, resulting in multibillion-dollar settlements with the government”

Johnson and Johnson, Risperdal, $2.2 billion Eli Lilly, Zyprexa, $1.4 billion Bristol Meyers Squibb, Abilify, $515 million Pfizer, Geodon, $301 million AstraZeneca, Seroquel, $520 million

http://healthland.time.com/2012/08/09/antipsychotic-prescriptions-in-children-have-skyrocketed-study/#ixzz246mvfUyx

Case Examples Caleb James

Josh Abigail

Summary What does THIS behaviour in THIS child at THIS time

mean?

Normal, Environment, Parent, GMC, Psychopathology

If there is a disorder:

Non-pharmacological approach

Medication options: risk:benefit in THIS child

Referral

Alternatively...