Download - Disruptive Behaviours
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DISRUPTIVE BEHAVIOURSDISRUPTIVE BEHAVIOURS
ININCHILDRENCHILDREN
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Autism SpectrumDisorders or Pervasive
Developmental Disorder
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Ty pes of PDD (ICD-10)
Childhood autismChildhood autismautistic ds, infantile autism, infantile psychoses, autistic ds, infantile autism, infantile psychoses, Kanner s syn d romeKanner s syn d rome
At y pical autismAt y pical autismRetts s y ndromeRetts s y ndromeChildhood disintegrative dsChildhood disintegrative ds
Overactive ds associated with MROveractive ds associated with MRAspergers s y ndromeAspergers s y ndromePDDPDD-- not otherwise specifiednot otherwise specified
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Diagnosis: 3 main areas of impairment inPDD or ASD
Delay and abnormal quality in:
reciprocal social interactionlanguage and communicationimaginative thinking - restricted,
repetitive activities and interests&
earl y onset : before age 3
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Social impairment
Qualitative impairment in reciprocal socialQualitative impairment in reciprocal socialrelationshipsrelationshipsnonnon- -verbal cues: poor e y e contact, facialverbal cues: poor e y e contact, facial
expressions, bod y postures, gesturesexpressions, bod y postures, gesturesfailure to develop peer relationshipfailure to develop peer relationshipfail to share enjo y ment or seek comfort whenfail to share enjo y ment or seek comfort whenhurt (lack of pointing, requesting)hurt (lack of pointing, requesting)difficulties with understanding social cuesdifficulties with understanding social cueslack of social empath y (difficult y tolack of social empath y (difficult y torecognise others emotions)recognise others emotions)
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L anguage & communication
Dela y in receptive and expressivelanguagestereot y ped or repetitive use of language
idios y ncratic use of wordsunable to initiate or sustain aconversation (those with speech)echolalia, pronoun reversal, invented
reduced gestures or poorl y co-ordinated(abnormal pointing)lack of social imitative or pretend pla y
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Repetitive stereot y ped activities andinterests
Rigid and inflexible thought processesresistance to change, insist on sameroutines, ritualistic behaviours(length y mealtime ritual)repetitive activities and interests(complex or simple)- hand flapping,twirling objects, fascinated withunusual parts of objects, samesegment TV show)persistent preoccupation with parts of objects
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Other features: not required fordiagnosis
Unusual responses to sensor y stimuli egcertain sounds, fascination b y certainvisual stimuli, dislike gentle touch, butenjo y s firm pressurepoor motor co-ordinationover or underactivit y
food fadserratic sleeping patternsabnormalities of mood- excitement/miser y
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Age of Onset
Dela y or abnormal functioning in atleast one area must be before age 3y ears
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PrevalenceChildhood autism:3-4 per 10,000 population20 per 10,000 (broader definition)
Asperger S y ndrome36 per 10,000
Male preponderance
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Differential d iagnoses of childhoo d autism
DeafnessDevelopmental language disorderMental retardation with autistic featuresMental retardation without autisticfeaturesIntense earl y deprivationPervasive developmental disorders:
Asperger S y ndrome, Retts s y ndrome,Degenerative disorder, at y pical
autism, PDD-not otherwise specified
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Treatment planTreatment plan
Establish goals for educationalEstablish goals for educationalpurposespurposes
Establish target symptoms forEstablish target symptoms forinterventioninterventionCoCo--morbid conditionsmorbid conditions
MonitoringMonitoringMultiple domains of functioningMultiple domains of functioningMedicationMedication
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The little RascalsThe little Rascals
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Attention Deficit Hyperactive Disor derAttention Deficit Hyperactive Disor der(ADHD)(ADHD)
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Hyperkinetic child ren
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Hyperactive parents
all manner of behaviours e.g. frequent night awakenings, talking lou d ly, naughtiness,
exu berance
depen ds on attitu des an d tolerance of parents MUST always pay attention to the stage of
develo pment when decid ing normality an d abnormality
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Hyperactive Children
Hyperactive
psychiatrists more restrictive definition
p restlessness
p inattentiveness
p impulsiveness
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Hyperactive Children
Overactive : increase in amount an d tem po of pur poseful activity increase in num ber of pur poseless minor movements
irrelevant to tasksT e.g. wriggle an d squirm in seat
fidget with objectsrestless
una b le to su pp ress activity when stillness is require dS e.g. in classroom or at meal ta b le
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Core sym p tomsCore sym p toms
HyperactivityHyperactivity More active than child ren their ageMore active than child ren their age
Inattentive Inattentive Short attention spanShort attention span
ImpulsiveImpulsive Poor impulse controlPoor impulse control
PervasivePervasive Sym p toms occur across all situationsSym p toms occur across all situations
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Hyperactivity Hyperactivity
Fidgets with han ds or feetFidgets with han ds or feetSquirms in seatSquirms in seat
Runs about or clim bs excessivelyRuns about or clim bs excessivelyDifficulty p laying or engaging in leisure activities Difficulty p laying or engaging in leisure activities quietlyquietlyTalks excessivelyTalks excessivelyAlways on the goAlways on the goDescri bed as if driven by a motorDescri bed as if driven by a motor
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Inattentiveness Inattentiveness
Fails to give attention to detailsFails to give attention to detailsMakes careless mistakeMakes careless mistakeDo not follow through instructionsDo not follow through instructions
Fails to com p lete schoolwork, chores or dutiesFails to com p lete schoolwork, chores or dutiesReluctance to engage in tasks requiring sustain Reluctance to engage in tasks requiring sustain mental effortsmental effortsDifficulty organizing tasks & activitiesDifficulty organizing tasks & activities
Easily d istracte dEasily d istracte dOften forgetful for their ageOften forgetful for their age
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Impulsive Impulsive
Blurts out answers before question Blurts out answers before question com p lete dcom p lete d
Difficulty awaiting their turnDifficulty awaiting their turnInterru p ts or intru des on othersInterru p ts or intru des on othersMakes poor judgementMakes poor judgement
Accident p roneAccident p rone
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Do you fit these criteriaDo you fit these criteria
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Epidemiology Epidemiology
Prevalent in 1Prevalent in 1--3% of child ren3% of child renMale : Female Male : Female 3:13:1
Hyperactivity dates back to p reHyperactivity dates back to p re --school yearsschool yearsReferral delaye d until p rimary schoolReferral delaye d until p rimary school Present with inattentiveness, learning d ifficulties Present with inattentiveness, learning d ifficulties
& d isru p tiveness& d isru p tiveness
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Management Management
Requires a multiRequires a multi --d iscip linary app roachd iscip linary app roach
Pharmacological treatmentPharmacological treatment
Psychological interventionPsychological intervention
Educational su pp ortEducational su pp ort
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PrognosisPrognosis
Hyperactivity wanes in adolescenceHyperactivity wanes in adolescence30% have resi dual sym p toms in adulthoo d30% have resi dual sym p toms in adulthoo d Restless & inattentiveRestless & inattentive
30% have no sym p toms with goo d functioning30% have no sym p toms with goo d functioning Choose job which allow free dom of movementChoose job which allow free dom of movement
30% continuous d isp lay of sym p tom30% continuous d isp lay of sym p tom Develo p other psycho pathologiesDevelo p other psycho pathologies
E.g. su bstance abuse & antiE.g. su bstance abuse & anti --social personalitysocial personality
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CONDUCT DISORDERCONDUCT DISORDER
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Con duct Disor derCon duct Disor der
3 d omains :* d efiance of someone in authority
* aggressive when relating to others* antisocial behaviour
- violates other peo p le s rights ,
p ro perty or person
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Con duct Disor derCon duct Disor der
None of these 3 is in itself - abnormal or pathological
Diso bed ience & d isru p tive behaviour- is part of normal behaviour- usually d iminish with maturity
Dx shoul d only be ma de when - behaviours are both extreme & p ersistent
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Con duct Disor derCon duct Disor der
Epidemiology- evolves over time- often persistent- boys more than girls- 6% to 16% b oys- 2% to 9% girls- onset : b efore 10 y.o or during
adolescence
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Con duct Disor derCon duct Disor der
Etiology
* no single factor* contri buting b iob io--p sychopsycho --socialsocial
factors
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Con duct Disor derCon duct Disor der
Biological factorsBiological factors
- p ro pose d neurotransmitter imbalance- excessive testosterone- abnormal arousal with failure to calm
down after frustration
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Con duct Disor derCon duct Disor der
Social factorsSocial factors- FamilyFamily
* chaotic home
* ver bal aggression * severe punishment* marital d iscor d* child abuse* p arental psycho pathology
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Con duct Disor derCon duct Disor der
Social factorsSocial factors- CommunityCommunity
* economically dep rive d* high criminality* unsu pp ortive social network
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Con duct Disor derCon duct Disor der
Psychological factorsPsychological factors- anger- frustration- hatre d- d issatisfaction
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Con duct Disor derCon duct Disor der
Diagnostic Criteria ( DSM IV )
- d istur bance for 12 months- involving at least 3 of the following
:
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Diagnostic Criteria
Often bullies , threatens or intimi datesOften starts fightsHas use d serious wea pons in fightsPhysically cruel to peo p lePhysically cruel to animalStealingHas force d someone into
sexual actsFire -setting to cause damage
Has destroye d other s p ropertyHas broken into a car or
houseCons othersOften out at night without permissionRan away from home overnight twiceOften truants , beginning un der
13 y.o
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Management
Prove d d ifficult to treatClinicians may feel overwhelme d
& ineffectiveMulti focus
- child focuse d
- family focuse d- community focuse d
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Factors p re d icting outcome
In the family- p oor outcome
* p arental psychiatric d /o* p arental criminality* high hostility* high d iscor d
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Opp ositional Defiant Disor derOpp ositional Defiant Disor der
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Characterise d b y an en during pattern Characterise d b y an en during pattern of behaviours :of behaviours :
negativistichostiledefiant
* in the absence of serious violation of - social norms or rights of others
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Caution :Caution :
Opp osing others is crucial to normal develo pment
Relates to esta b lishing- autonomy- forming identity
- setting inner stan dar ds & control
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Caution :Caution :
Child ren may have strong tem peramental p re d isposition
- strong will- strong p references- great assertiveness
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PathologyPathology
If power & control are issues for parentsOr if parents exercise authority for their own nee ds
- the ensuing struggle can set stage for develo pment of d /o
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PathologyPathology
What begins for a child as an effort to
esta b lish self -d etermination- is transforme d into a defense
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Diagnostic Criteria Diagnostic Criteria DSM IVDSM IV
Distur bance for 6 monthsInvolving at least 4 of the following sym p toms :
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Diagnostic Criteria Diagnostic Criteria DSM IVDSM IV
Often loses tem perOften argues withadultsOften defies adult requests & rules
Often deliberately annoys others
Often shifts b lame to others
Often touchy or easily annoye dOften angry & resentfulOften sp iteful or vind ictive
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Opp ositional Defiant Disor derEpidemiology
- p revalence in general population * about 1 .5 %
- male : female ratio* 2 : 1 to 3 : 1
- p eak age of onset* early childhoo d
- onset after age 10 years* unusual
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Opp ositional Defiant Disor der
Course* sym p toms persist to adulthoo d
- in up to 14 %* association with CD
- is strong
* 56 % shows imp rovement- with psychothera py
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M anagement
Ind ividual Psychothera py- to restore self -esteem
Behaviour mo d ification- reinforce & p raise app ro p riate behaviours
Counsel parentsParenting skillsSocial skills training- learn new strategies to develo p sense
of success in social situations
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