Behavioral & psychiatric problems in children
Dr Wrishi Raphael
All young children can be naughty, defiant and impulsive from time to time, which is perfectly normal. However, some children have extremely difficult and challenging behaviours that are outside the norm for their age.
The most common disruptive behaviour disorders include oppositional defiant disorder (ODD), conduct disorder (CD) and attention deficit hyperactivity disorder (ADHD). These three behavioural disorders share some common symptoms, so diagnosis can be difficult and time consuming. A child or adolescent may have two disorders at the same time. Other exacerbating factors can include emotional problems, mood disorders, family difficulties and substance abuse. But thankfully some troubling behavioural patterns may be less troubling then
the others.
Breath holding spells
Extremely frightening for
parents
Peak incidence at 1-3 yrs of age
Most common type of breath-holding spell is a cyanotic spell (condition where fingers, toes may become blue due to lack of
oxygen)
In response to relatively minor frustration or a painful stimulus, the child cries briefly before involuntarily holding the breath in expiration and become rapidly cyanosed
Occasionally, loss of consciousness or even a brief hypoxic seizure results
Management:
Need to be distinguished from seizures
Place the child on its side until spontaneous recovery
Do not provide the child excessive attention
Temper Tantrums
Developmentally normal for toddlers to express frustration as they strive for autonomy and some control over their world
From the second year of life most children will have it, often persisting through to preschool years
Management
Positive reinforcement of socially acceptable behaviour and negative reinforcement of undesirable or unacceptable bahaviour is beneficial.
Ignoring is effective for tantrums
Separation anxiety disorder
Excessive and developmentally inappropriate anxiety on separation from primary caregiver with physical or emotional distress for at least two weeks
On average the effected children are 7 years old at onset and 10 years old at presentation
School refusal is very common
Persistent worry, refusal to sleep, clinging, nightmares, somatic symptoms
Co morbid major depression is common (2 / 3)
Children are often apprehensive about something happening to parent or themselves
Treatment
Family and individual psychotherapy
Behaviour modification techniques, stress reduction, parental education, predictive and supportive environment, relaxation techniques
Pharmacotherapy: SSRIs (e.g. fluoxetine), benzodiazepines
Conduct disorder
Pattern of behaviour that violates rights of others and age appropriate social norms with 3 in past 12 months and 1 in past 6 months:
Aggression to people and animals (bullying, physical fights, use of weapons, forced sex)
Destruction of property, firesetting with intent to damage
Deceitfulness or theft (breaking and entering, car theft)
Violation of rules
Disturbance causes clinically significant impairment in social, academic, or occupational functioning
If individual is 18 years or older, criteria not met for antisocial personality disorder
Treatment
Early intervention necessary and more effective, long-term follow-up required
Parent management training, anger replacement training, CBT, family therapy, education / employment programs, social skills training, medications for aggressiveness or comorbid disorders
Pharmacotherapy is insufficient; mainly used for treatment of comorbid disorders
Prognosis
50% of CD children become adult ASPD
Oppositional Defiant Disorder
Pattern of negativistic /hostile and defiant behaviour for 6 months with 4 of
Loses temper, argues with adults, defies adult rules, deliberately annoys, blames others, touchy / easily annoyed, angry and resentful, spiteful or vindictive
Behaviour causes significant impairment in social, academic or occupational functioning
Behaviours do not occur exclusively during the course of a psychotic or mood disorder
Criteria not met for CD; if 18 years or older, criteria not met for ASPD
Features that typically differentiate ODD from transient developmental stage: onset 8 years, chronic duration (6 months), frequent intrusive behaviour
Impact of ODD: poor school performance, few friends, strained parent/child relationships
May progress to CD
Treatment
Establish generational boundaries
Parent management training and psychoeducation
Individual / family therapy
Pharmacotherapy for comorbid disorders
School / daycare interventions to help with behaviour management
Attention Deficit Hyperactive Disorder
Around two to five per cent of children are thought to have attention deficit hyperactivity disorder (ADHD), with boys outnumbering girls by three to one. The characteristics of ADHD can include:
Inattention difficulty concentrating, forgetting instructions, moving from one task to another without completing anything.
Impulsivity talking over the top of others, having a short fuse, being accident-prone.
Overactivity constant restlessness and fidgeting.
Treating ADHD
There is no cure for attention deficit hyperactivity disorder (ADHD), but treatment can help relieve the symptoms and make the condition much less of a problem in day-to-day life.
ADHD can be treated using medication or therapy, but a combination of both is often the best way to treat it.
Treatment will usually be arranged by a specialist, such as a paediatrician or psychiatrist, although your condition may be monitored by your GP.
Medication
There are four types of medication licensed for the treatment of ADHD. Drugs like Methylph-enidate and Atomexitine are used. These medications are not a permanent cure for ADHD, but they can help someone with the condition concentrate better, be less impulsive, feel calmer, and learn and practice new skills.
The writer can be reached at: [email protected]
