Upload
others
View
5
Download
0
Embed Size (px)
Citation preview
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...